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CITY OF DIAMOND BAR � �
�----��`-- DEPARTMENT OF COMIv1UNITY&DEVELOPIvIENT SERVICES ��1?���
� 21825 E.Copley Drive
" (909)860-3195 Fax(909)861-3117 `��� PRESS
``:.�'.w BUILDING PERMIT APPLICATION P�� FIRMLY
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DESCRiPTION S�.Ff. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATION SFR/ADD/REM
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� I HEREBY AFFIRAI UNDER PENAL7Y OF PERNPV THAT I AM EXEMPT FROM THE CONTRACTOPS LI� G8f9gB/C9fPOfI
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U COUNTVWHIqiREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANI'STRUG W PafIO/DBGK � Z
W1UqE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPUCANT FOR SUCM PERMIT TO FILE A SIGNED W � �
� STATEMENT THAT HE OR SHE IS IJCEN5E0 PURSUANT TO THE PqOVISiONS OF THE CONTMCTORS LI-
� CENSE lAW(CHAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � PooUSpa
O fESSqNS CO�E)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIS FOR THE ALLEGED E%EMP-
V TION.ANYVIOLATIONOFSECTION7031.6BYANYAPPLICANTFORAPERMITSU&lECTSTHEAPPUCANTTO Z Re-Roof
� A CIVIL 7ENALTV OF NOT MORE THAN FIVE NUNDRED DOLLARS(f500�.):
� L71,ASOWNER�FTHEPROPEFr'(,ORMYEMPLOYEESWITHWI.GESASTHEIRSOIECOA/PENSATIQN, 0 COf11rt1BfC12I
Z WILL DO THE WOHK,AND THE STRUGTURE IS NOT INTENDED OR OFFERED FOR SALE(SEL.70a�,BU51� J
� NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PFOPEFIYVOFIOBUILDSORIM7ROVEST1iEREON,ANDWHODOE55UCHWORKHIMSELFORHERSELFOR m
� THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
W OFFEREDFORS/�LEIF,HOWEVERTMEBUIID�NQOHIMPROVEMENTISSOI�WITHINONEVEAROFCAMPLE�
0� TION,7HE OWNER-BUILDER WILL HAVE THE BURDEN OF PFOVING THAT HE OR SHE DID NOT BUIID OR
Z �MPROVE FOH THE PURPOSE OF SALE).
= O l�5 ONTJEROF THE PAOPEHTY.AM EXCLUSIVE�V CANTRACTIN�WfTH UCENSED CONTRAC70R5
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� TO CONSTRUCT TME PROJECT(SEC.70N,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U- V81U8I1011 � Z ADJ.AREA
� CENSE UW OOES NOTAPPLV TO AN OM?JER OF A PROPERN WFIO BUILDS OR IMPROVES THERE-0N.AND
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� O I AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON �
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� DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION —�
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I HEREBYAFFIRM UNDER PENALTV OF PERIURV THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER �
� 0(COMMENCINO WITH SECTION 7000)OF DNISION 3 OF THE BUSINE55 AND PROFESSIONS CODE.AND Z
X MV LICENSE IS W FULL FORCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION J
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECLARATIONS: Z
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Q �I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' 2
Q COMPENSATION,AS PROVIDED BY SECTION 370o OF THE LABOR CODE,FOR THE PERW RIAANCE w
� OF TI4E WORX FOR WHICH THIS PEf1M{T IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTKKJ
Q 37000FTHE LABOR CADE,FOR THE PEFFORMANCE OF THE WORI(FOR WHICH THIS PERMIT IS
ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIER AND POLIC�NUMBER ME: CONSTRUCTION 4
� CARRIER �NS7J PLAN REVIEW , � v
n POI.ICVNUM9ER P�w�,_)�_� �'(j_Z��u+'� � ELECTRIC
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� �n-i�ssEcratrNFIDraTaEo�nettFrmoFn�aEarrtrscnaa+e�E000uoas�s�m�aa�Essl PLUMBING
W MECHANICAL
Z I CELITIFY THAT IN THE PERFORAIANCE OF THE WORK FOR WHICH THIS 7ERMIT IS ISSUED,I
(} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE INSPECTION FEE
� WORKEFS'COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SFIOULD BECOME
SUBJECTTOTHEH'ORKERS'COMPENSATIONFiiOVIS10N50FSECTION37000FTHELABOH ISSUANCE
OCAOE,I SHALL FORTFIV/IiH COMPLV WITH THOSE PROVISIONS. I�',��/� � fC
p DATE:��d/�z APPLICANT: -;3�'��«NNY ✓�'�N� SMIP ��v .
� ENERGY P/C
WARNINa:FAIIURE T0 SECVRE WOFKERS'COMPENSATKKJ COVERAGE IS UNLAWFUL,rWD SHALL BE
�y SU&1ECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(S��.W01.��DITION TO'f}iE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF 7NE LABOR CODE,INTEREST,AND ATTORNEYS FEES. RETENTION FEE: �'�
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w CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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CC� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THATTHERE IS ACONSTRUCTION LENOINQ AOENCV
�d FOR THE PERFORMANCE OF THE WORN FOR WHICN THIS PERMIT IS ISSUED�SEC.JOB�,CIV.C.).
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� LENDER'S NAME
1-_- LENDER'S WORESS ��/►
� ICERTIFVTHATIHAVEFEADTNISAPPIICATqNANDSTATETHAThIEABOVEINFORMATIONISCORRECT TOTAL FEES ��.�^� ��/ �
w I AGREE TO CAMPLV WITH ALL CITV AND CWNTV ORDINANCES AND STATE LANS RELATING TO BUILDING V"
� CONSTRUCTION,AND HEREBV AUTI-IORIZE REPRESENTATNES OF THIS COUNTY'f0 ENTER UPON THE �
Z AflOVE-MENTqNEO PROPERTY FON INSPECTION PURPOSES.
COMMENTS
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� SI�N� OF PERMITTEE D E
RECPT.NO. PAID BY VALIDATION
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�"" ITE—Depariment Copy.YEIIOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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GROUND PWMBING � UNDER FLOOR CU�IDUIT
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. SUND f3EAM
ROOF SHEATHING 8 FT. BOND BEAM
FRAMINGNENTfUATION FINAL B4IJD BERM
ROOF CaVER PRE-GRADING
ROUGF-t HEATING SENCHlNG
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUNIBING FINISH GRADING
SHOWER/TUB TES7 POOL ELECTRIG
EXT. LATH/SIDINCa POOL FENCING
WALL It�SULATION POOL FINAL
CEILING IIVSULAT(ON OFF SITE IMPS.
DRYWALL i�AILING DEDICATIONS
SEWER FINAL ENG. -
SEPTfC TAtVK LANDSCAPE/tRR1G.
SEEP PtT/L.L. ON SITE IMPS.
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