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1��_ CITY OF DIAMOND BAR �2�
_,,, � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � -----""—��
�,W . 21810 Copley Drive,Diamond Bar,CA 91765
. (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
' ��'�^'. BUILDING PERMIT APPLICATION FIRMLY
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W NRE,PRIOR TO RS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W Patio/Deck
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�Q LICENSED CONTRACTORS DECLARATION w
CL 1 HEREBY AFFIRM UNDER PENALTY Of PERIURY THAT I AMlICENSED UNDER PROVISIONS OF CHA7TER � � � .
� 9�COMMENCINO WITH SECTION 7000)Of DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE,AND Z
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� WORKERS'COMPENSATION DECLARATION Q
� 1 HE�FFIRM UNDER PENALTV OF PERJUHY ONE OF 7HE FOLLOWWG DECLAMTIONS: Z � �
� _1 HAVE AND WILI MAMTAIN A CERTIFICATE OF 60NSENT TO SELF•INSURE FOR WORNERS' _ �
� COMPENSATION,AS PROVIDED BY SECTION 37000F THE UBOR CODE,FOR THE PERFORMANCE W
Q OF THE WORK FOR WHICH THIS PERMI7 IS ISSUED. � � -
w �I HAVE AND WILL AUINTAIN WORKERS'COMPENSATION INSURANCE,AS REWIRED BY SECTION � �
Q 37000F THE IABOR CODE,FOR THE PERFORMANCE OF THE WOHI(FOR WHICH THIS PERMIT IS. [�/'�
ISSUE�.MV WORNEAS'COMPENS TION iN5 RANCE CARR1IE_R�ApND PO/L�ICY NUMBER ARE: �CONSTRUCTION ��.W
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� POL�CY NUMBER_��_:o �� . . . ELECTRIC
0 (�HIS6ECf10NNE�NDTBE00RFLEfIDOF71-IEPERMTISFORONEHIA�DRmpOILAiLSR10010RLFSS) PLUMBING � . �
Z �CERTIFY THAT IN hiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.I �MECHANICAL
C} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SU&IECT 70 THE �
� WORKERS'CAMPENSATION UWS OF CALIFORNIA.AND AGREE THA7 iF I Sh10ULD BECOME INSPECTION FEE
? SUBJECT TO THE WOHKEtiS'COMFENSATION PROVISKKJS OF SECTION 3700 OF THE UBOR " - /D `
COO,1 SH3ALL FOHTHWITH COIAPLY WITH THOSE P OVISIONS. ISSUANCE l -�7
p DATE: ��J�I�-qpp�ICANT: ��I�I�`C��� �SMIP + / O
J WARNIN6:FAIWRE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUWFUI.AND SHALI BE ENERGY P/C
�y SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FWES UP TOONE HUNDRED THOUSAN� ENERGY PERMIT
DOLURS.(S10o,000),IN MDITON TO THE COS70F CAMPENSATION,DAWAGES AS PROVIDEDFOR IN /�
� SECTION 37oe OF THE LA80R CODE,INTEREST.AND ATfOflNEY'S FEES. � RETENTION�FEE: q �.O v
OCONSTAUCTION LENDING AGENCY P9E-/�T FE • '/1
� 1 HEREBYAFFIRM UNDER VENALTY OF PERIURV THAT 7HERE IS ACANSTRUCTION LENDINO AOENCY /J S . v �
�FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED�SEC.3087,CIV.C.).
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� LENDER'S NAME
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� �I CER7IFY THAT I HAVE READ THIS APPLICATION AND SUTE 7HATTHE ABOVE INFORMATIDN IS CORRECL TOTAL FEES ' � v / �_
� w 1 AGREE 70 CAMPLY N7hl ALL CITV AND COUNTY ORDWANCES AND STA7E UWS REUTING TO BUILDINO
� CONSTRUCfIOIy AND HEREBY AUTFIORIZE REPRESENTATNES OF THIS COUNTY TO EMER UPON iHE �
� ABOVE-MENTIONED PROPERTY FOR INSPECTION PUR705E5.
Z COMMENTS '
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� S F PERMITTEE DATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—DepaAment Copy,YELLOW—F'u�ance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanCs Copy
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SET BACK i FLOOR)OIST
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FTGS/FORMS/STEEL __ �FHAREQMTS__________ __ _ ____ __
ELECTRIC GROUND !UNDER FLOOR DUCT
GROUi�D PLUMBING �UNDER fL00R CONDUIT
SLAB GRADE i FIREPLACE FOUNDATION
TEMP PObVER i FIREPLACE BOND BEAM
WATER SERVICE I MID HT.BOND BEAM
ROOF SHEATHING ;8 FT.BOND BEAM
FRAMING/VENTILATION �FINAL BOND BEAM
__._..------- -------.. ._ ..----____ ._.._ _ -- --. ---- ------.__ __ ____ ---- --. ------ -- --------
ROOF COVER PRE-GRAQING _ _ ___ _ ___ _____ __ __ ___
ROUGH HEATING ;BENCHING _
ROUGH ELECTRIC i ROUGH GRADING
ROUGN PLUMBING �FINISH GRADING
SHOWER/TUBTEST I POOL ELECTRIC
EXT.LATH/SIDING �POOL FENCI�G
WALL INSULATION �POOL FINAL
CEIUNG INSULATION �OFF SITE IMPS.
DRYWALL NAILiNG I DEdICATI0N5
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SEWER �FINAL ENG. ,
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SE�TICTANK i LANDSCAPE/IRRIG.
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SEEP PIT/L.L. I ON 51TE IMPS.
GAS AIRTEST FINAL ZONING
FINAL CONST. j FIRE DEPT.FINAL
FINAL HEATING rHEALTH DEPT.FINAL
FINAL ELECTRIC 'DEV.FEES PAID
FINAL PLUMBING �ENERGY
FINAL PLANING I
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FINAL ENGINEERING ' o e
COMMENTS _ _ --
SEPTICTANI{SIZE
SEEP PITIU SIZE
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TuIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose signature
"" on this certificate,who is a recognized authority of accuracy, as prescribed by chapter 7 (commencing with section12700)of Division
5 of the California Business and Professions Code, administered by th Division of Measurment Standards of the CA Department of Food
and Agriculture.
Weighe8 at: Account: 0417260001/SELF HAUL COt Ticket: 1075501 �
Grand Central Recycling&Transfer Station SELF HAUL CONCRETE 9/12/2012 I
City of lndustry Yard
999 South Hatcher Avenue ,CA-
Industry, CA 91748
Carrier: SELF CGSELF HAUL CREDIT CARDS ',
Truck: 79716D1 Manifest: VISA �
Route:
Gross: 539601b In Scale 2 9/12/2012 1:02:53PM Comments: JESUS
Tare: 241801b Out Scale 2 9/12/2012 1:15:42PM
t�1et: 2978o1b I N B O U N D L O A D
Tons: 14.89
Origin Materials&Services Quantity Unit Rate/Unit Amount
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DIAMONDBR/Diamond Bar CONC60/Concrete Clean$60 Load 14.89 Ton $60.00 Min $60.00
, Total Amount: $60.00
, Visa: xxxx-xxxx-xxxx-7062-Approved: SALE:051516:22562020: $60.00 I
Change: $0.00
Received.by: Driver:
Deputy(s): Gross by V. MARTINEZ -- -�i;`-_ �?. ;�`-i
Tare by V. MARTINEZ
.e s.o p+�wnvu nn.as �
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���� �Attachment A
Form for Non-Franchise Haulers for Construction and Demolition Debris
Company and Project Info:
Name of licensed demolition contractor hauler or self hauling company c�1 ��
Address of Company 7� Z � d�Q� /�l�i-� ��11►� City ����1 ` �
Zip Code / D 6 p� Phone Number 7�� r g � � (� (
Address and Name of Project Site
�� �`� C�S��Y`m C� .J�'d� �_9�c� \����\��.Q��O
Type of recycleable material or waste material to be transported for this project
� �" " � �� �' l�s�c ea SM��
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Report Information:
Please submit this information prior to fmal building inspection.
A report reflecting the following information:
• The estimated volume or weight of construction and demolition debris,listed for each
material;
• The estimated volume or weight of construction and demolition debris that can be i
diverted listed for each material;
• The estimated volume or weight of construction and demolition debris that will be
landfilled as waste; and
� Identification�of the vendor or facility that will collect or receive the construction or
demolition debris. �i
AB 939 Fee Payment:
Pay AB939 fee of$12.00 per bin and$50 per roll off for all non-franchise hauler containers
Type of Container number of container
Paid date(office use only) (revenue code CD Waste) .
Agreement and Signature:
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold harmless the City for damage and
liability, including any financial liability, fines and penalties, associated with using a non-City
franchised hauler and failing to satisfy diversion requirements.
�
p r Sign e Print Name Date
� /(�c-J'� i � �eo S-3� 12
�
elf Hauler Signature Print Name Date
Last updated June 26,2008