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�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUiVITY&DEVELQPMENT SERVICES
W 2266Q E.Cogley Drivo Suite 19Q
(909)86Q-3145 F�(909)861-3117 PRESS
�'°�'� BUILDING FERMIT APPLICATION FIRMLY
� DDRESS�/OIC� Ct?PCE� �]> �DO�L �ps.D LZ� (}ATEICATION _��� � NUMBER �`+"'� �` #/C
� �SSUE TYPE OCC
APN LOT T ACT DATE CONS7. CiROUP
p OWNER ���_.
� ADDRfSS' ;` �' ZON�NG SETBACKS
w CITY�a� � E�. FRONT RW t�_
� APPUCANT _ EL. REAR U
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� GITY ES r�..ZEP �> EL .1- PROPOSED U$E FF!C� 'f
� ARGH/ENG/ �C`�
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v� OESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATI4N
� QWNER-BUILDER DECLARATION SFWADOtREM
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1 HERE9Y AFFIRM UWDER PENAI.TV OF PERJUpV THAT I AM EXEAIPT FRqM THE CONTRACTORS LI- GaCfl9B/CHfpOt[
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TURE,PRqR TO IT5 IS94ANCE,ALSO RE9UIRES THE APPLICAN7 FOR SUGH PERMI77o FILE A SIGNED W
� STATEMENT THAT HE Op!:HE IS LICENSED PURSUANT i0 TME PI�YISION5 OF TH�t�AtTRACT�i.i- � �
� CENS6 tAW(CHAPTEA G(tpMM[NCIN4 W11H SECT�ON 7GOoj OF OIV1510N 3 pF TME BUSINE55 AN�PRO- POOI/S(.18
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� A CIN�VENALTY OF NOT MORE 1'HIW FNE HUNORED OIX.LARS(5500).):
� ❑I,ASOWNEROFTHFPRQPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSALION, �m����f
M1�1.DO THE WOAK M!0 1liE 5TRt7CTURE IS NQT lNTENEIED OR OFF6RED F6R SALE jSGC.7oMt,8US4 �
� NESS AND PROFE$SIONS IXIDE:THE l."OM�RACTORS LICENSE LAW DOES NtS7 APPLY TO AN OWNER OF �
PROP�KTY W!p 8U1LDS Ofi IMpR�VES THEiiEON,ANDYAiO DOES SVGi WOflK MIA6ElF Oft NERSELF OR
CL THFiOUGH tNS OR NERd�lIQ EMPI�YEES,VRpVIDED THAT SUCH IMPROVEMENiS ARE NOT MTENDED OR m "
� OFFEREDfOIiSALEIF,HOY/EVERTMEBUILpINGOHIMPROVEMENTI550LDWITMINONEVEAqOFCUMPLE-
� 710N,TME fM/NEH�UILDER iMtl MAVE THE BUf�EN OF PflOYRiG TNAT HE OR SHE OID NqT 6UItD OFi
� IMVP4VE FQR THE PURPOuE OF SALE).
�y ❑I,ASt}WNEpOFTHf:PF4PERTY,AMEXCLUSIVELVCONTflACTINi3WITHLICENSEDCONTRACTOpS
� To coHSTaucr n�rr%�cT{s�c.ra�+,aus�xEss a�P�ssiaus caoE�n+K cadrw.cToas u�� Vaivation � ADJ.AREA
CEN9E LAW pOES NOTAPPLY TtJ AN CINMER OF A PROPERTV WFIO Bl1M.DS Op IMPROVES THEHEQN,ANp '
� VA10C%?NTMCTSFORSUCHPRQIECTSWITHACONTMC70R(S)IICENSEDPUPSUM}TTOTMECONTMG QUAI'ITITY DESCRtPTION FEE
� TOHS UCENSE uW.).
q 1 AM EXEMPT UNOFR SEC e.&PC.iOR THIS REASON J
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� �ICENSED CIXdTRAGTORS DECIARATION �
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I MEREBYAFFIqM UNDER PE:NALTY OF PENUFiY THA7 I AM LICENSED VNDER PqOVISIQNS OF CHAPTEft �
Q 4(CX7MMEHCNQ WiT}f SEC7pN T6W)bf DiViSI041 3 OFTHE HUStNE55 ANO PP4FESSiONS CODE,AND Z
u� MY LICENSE IS IN F41LL FOFd�E ANo EFFEC7. m
� LIGENSE/CtASS/ � ��__ LIC.NO. ���7»7 • � �
� OATE �C�`�l�`C II CONTRAC7bR d
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4 OF THE WOFlK FOR VYHICH TNIS PERMIT IS IS5UEp. �
w _^_i NAVE AND WILL MAIMA�N WORKERS'COMPENSA710N INSURANCE,RS REOUfRFD BY SECTION
dQ 910o OFTHE LABOP GODE.FOR THE PERFOpMANCE OF THE WORK FOR WHICH THIS PERMlT IS
ISSVEO.MYWOftNERS'WMPENS/AT�RN��II�NSURANCECARRIERANOPAtiCYNUMBEflAAE CONSTRUCTIQN
}�. CAqftIER_���TE f'Y/NQ PLpN REYIEW „ �
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Z i CERf'IFY THAT$7 THE PERF6RMANCE OF tHE WORK iaR NM1iICH THfS PERMIT IS I5SUE6,I MECHANICAL „ ,,,_,
(',�j SHALL NOi EMPLOY.WY PERSCIN IN ANY MANNER 50 AS TO BECOME BU&IECT TO THE ��
(;/) WORKERS'COMPEN>ATIQNUWSOFGALIF6ANIA,ANCAf3REETNA7IFiSNOUtt?BECOME INSPEGTIONFEE __ �
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CA�E,1 SHAILFOFTNWITFI CdAPLY WITH P I N ISSUANCE
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�j,,, SUBJECTAN EMPLOYER TO LRIMINAL PENALTIES ANb CIVR FlNE$UP TD ONE MUNDflED TMOUSANU ENERGY PERMIT
DOLUFi5 jit00,000).W ApDiT10N T0 LHE COST flf CQMPENSATpN.QAMAGES AS AROYi�ED FOR(N
� SECTNJN 31080F TH€LABUR CQDE,INTEflEST,AND ATTORNEY'S FEES. RETENTION FEE:
� C6NSTRUCTfON LENDING AGENCY PHEALT FEE: __
4 1 NERE9Y AFFIflM UNQE#i PEMALtt OF F6RJURY THpT THERE IS A CONSTRUCTlOM CEtiDiNG AGENCY
FOR THE PERFOFMANCE OF 7HE WORK GOP WHICN THiS REAMIT 15 ISSUEO i58C.]oe7,CIV.G.).
W _...
� IENDERS NAME ,,,, _„ �
t-^ �ENDER'SADDRESS �/
� !CERTIFY TNAT f NME REAR 7"HIS APPliCA710N AN�57ATE TliAT TFiE ABOYE iNFORMATiflN!3 CORqECi TIJTAL i���S ��t�V l!
� I A�REE TO CC1i.tPlV WITH ALt.dTY AtiO CWNTY ORQINANCES ANq STFTE UWS RELATING 70 BVL�ING
� CONSiRUCT10N.M1D HEREBI'AUTHOFIZE REPfiESENTATNES OFTHIS COVNTYTO ENTEq UPON THE
MTK]MEO RROGERTY fORlNSPECTKIN PVRPOSES. CQMMENTS
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UINIMONU III
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ADDRIESS2410 eaUCY ZP FLQO/L t P 2
APN LOT T ACT
OWNER
ADDRESS'
CITY EL.
APPLICANT EL.
CONTRACTED
ADDRES
CITY L1+�ZIP EL 1-
ARCH/ENG/D(1L
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT.ALTER. IMPROVE, DEMOLISH. OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TON.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I.AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044. BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE VEAROF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJIECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
Q1
LICENSE
CLASS
LIC. N0. c-79
r
/
DATE F C CONTRACTOR A I W' r-AekA&W;11
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
-1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER s77
I I,D
s
POLICY NUMBER_�LF„d n
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKNI LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITHJJIC�pR I�ASN
ATE
PP
A
N/
A
D
LIC
NT
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CO RAGE IS UNLAWFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
NTIONED PROPERTY FOR INSPECTION PURPOSES.
� 1.- �--
RMITT NAME(PRINT)
L(�Cr'
SIGNATURE OF RMITTEE DATE
CITY OF DIAMOND BAR el "III
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION PERMIT I I C" P/C
DATE NUMBER #
ISSUE TYPE OCC
DATE CONST GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDEISIDE STREET RW ^
SIDE ^
PROPOSED USE FFf Col Q
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM
C/) Garage/Carport
LU Patio/Deck
UJ
LL PoOVSpa
Z Re-Roof
0 Commercial
Ib
Valuation 25 ADJ.AREA
QUANTITY DESCRIPTION FEE
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U
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U
W
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
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INSPECTION FEE
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ENERGY P/C
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RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 15,'J'G
COMMENTS
RECPT. N0. PAID BY I'IMVALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
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