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---�� -- CITY OF DIAMOND BAR � ) Y�
� DEPARTME?�.r1'OF COMMUNTI'Y&�DEVELOPIvIENT SERVICES �
21825 E.Copley Drive
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�"%9��' BUILDING PERMIT APPLICATION FIRMLY
o� ' JOBSITE �j�3(��S,v ///� � APPLICATION, � PERMIT P��r � P/C
ADDRESS ��� DATE NUMBER� 1�� �
� ISSUE TYPE OCC
APN LOT TRACT DATE �CONST. GROUP
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ'.AREANALUATION
p� OWNER-BUILDER DECLARATION SFFUADDlAEM
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I HEREBV AFFlRM UNDER PENALTV OF PERRIRV THAT I AA1 E%EMPT FROM THE CONTRACTORS LI- G8f8 6/CAfpOR
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W CENSELAWFORTHEFOLLOWINGREASON(SEC.703t.5BUSINESSANDPROFE5510NSrODE:ANYCITVOR (n
U CIXJNTyWHICHREOUIRESA7ERMRTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANVSiRUG
W NHE.PRIOR TO ITS ISSUANCE.ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� STATEMEM TFIAT HE OR SHE IS LICENSED PURSUAflT TO THE PROVISIONS OF THE CONTMCTORS LI- .
� CENSE UW(CHAPTER e(COMMENCING WITH SECTION�000)OF DIVISION 3 OF THE BUSINE55 AND PRO- � POOUSPB
^ FESSqNSCODE)OflTHATHEORSHEISEXEMPTTHEREFROMANDTHE0A515FORTHEALLEGEDEXEMP- (�
V TION.ANV VIOLATION OF SECTION 7031.5 BY ANV APPUCAN�FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
A CML PENALTV OF NOT AqRE THAN FNE HUNDRED DOLLARS(f5o0),�:
� ❑I.ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWI7HWAGESASINEIRSOLECAM7ENSATiON, � COrt1RIefClel
Z WILL DO THE WORK,AND THE STRUCNRE IS NOT IN i ENDED OR OFFERED FOR SALE(SEC.70a�,BU51- J
� NESS AND GROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NO'APPLY TO AN OWNER OF �
PROPERTV WHO BUILDS OR IMPROVES THEREON,AND NMO DOES SUCH WORK HIMSELF OR HERSELF OR
wTHRWGHHISORHENOWNEMPLOYEES.PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR m
� OFFEREDFORSALEIF,HOWEVER711EBUILDINGORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE-
Z TION,THE OWNER�BUILDER WILL HAVE TME BURDEN OF PROVWG'HAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR TME PUflPOSE OF SAIE�.
w ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELVCONTRACTINCWITHLICENSEDCONTRACTORS
� TO CANSTRUCT TME PR0.IECT(SEC.70Ia,OUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U� V01UBIi011 � ADJ.AREA '
W CENSE UW DOES NOTAPPIV TOAN OWNER OFA PROPERTV WHO dUII.DS OR IMPROVES THEREON,AND
� NRIOCANTRACTSFORSUCHPROJECTSWITHACANTRACTOR(S)LICEI:SEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE
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� O I AM EXEMPT UNDER SFC. B.d P.C.fOR THIS R ASON Q
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� LICENSED ACTORS DECLA ATI w , ,
� I HEREBV AFFIRM UNDER PENALTY O P URY THAT I AM IICENSED U R PRO NS OF CHnPTER �
� B(COMMENCINO WI7H SECTqN 7000 O DIVISION 3 OF THE BUSINESSAND PP.O IONS CODE,AND Z
LLI MV UCENSE IS IN FULL FORCE AND E ECT. m
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� WORKERS'COMPENSATION DECLARATION Q
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N I HEREBYAFFIRM UNDER PENPITY OF PER1l1RV ONE OF THE FOLLOWING DECLARATIONS: Z
�Z _I HAVE AND WILL MAINTAIN A CEHTIFICATE OF COtJSENT TO SEIF-INSURE FOR WOHNERS' a
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COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LA80R CODE,FOF THE PERFORMANCE U
OF TME WORK FOR WMICH THIS PERMIT IS ISSUED. �
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w _I HAVE AND WILL MAINTAIN WORICERS'CAMPENSATION INSURMICE,AS RE�UIRED BV SECTION
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I��Y T
ISSUED.MV WORNERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION V
� CARRIER PLAN REVIEW �
Z POLICYNUMBER ELECTRIC
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� (iF165ECT10NNE�NOTBE00MREfEDOFhEPEPoMISPoFONEMII�[N�EDDOLLARS�StaO�OqLESS). PLUMBING
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Z I CERTIFY hIAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL '
C.'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME SUBJE�T TO THE
(fj WORKERS'COMPENSATION lAWS OF CALIFORNIq AND AGREE THAT IF I SHOULO BECAME INS?ECTION FEE
'= SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 7]OOOF THE LABOR
CODE.I SHALL FOFTHWITH COMPLV WITH TFfOSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT: SMIP �_
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J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFMESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLURS(f100.000).IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3�OB OF THE LABOR COOE,INTEREST,AND ATTOFlNEV'S FEES.
w RETENT�ON FEE: _ �
O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: '
� 1 HEREBV AFFIFM UNDER PENALTV OF PERJURV THAT THEFE IS ACONSTRUCTION LENDING AGENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH iHIS PERMIT IS ISSUED(SEC.9081,CIV.C.�.
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� LENDER'S NAME
F'- LENDER'SADDRESS
w ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEWFORMATIONISCORRECT. TOTAL FEES �G�I �/�
� I AGREE TO COMPIV WITH ALL CITY AND COUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING O
� CONSTRUCTION,AND HEREBV AUTINJRRE REPRESENTATIVES OF TMIS CWNTY TO ENTER UNN THE
z ABOVE�MENTIONED PROPERTV FOR INSPECTKKJ PURPOSES.
0 ,� r /a� � COMMENTS
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SIG T DATE
_ � RECPT.�O. PAID BY VALIDATION
~ WHITE—De a� ent Co YELI.OW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—Applicant's Copy
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FTGS/FORMS/STEEL FHA REQt41TS
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ELECTRIC GROUND � i UNDER FLOOR DUCT
GROUND PLUMBING � UNDER FLQOR CU�IDUIT
SLAB GRADE FIREPLACE FOUNDA710N
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE � MID HT. BOND BEAM
-- ---- -___ _ __ _----- ---
ROOF SHEATHING • __, I 8 FT. BOND BEAM �
_ _ � 7_
FRAM►NGNENTILIATION � ; FINAL BOND BEAM
ROOF COVER PRE-CRADING
ROUGH HEATING BENCHING �
ROUGH ELECTRIC R�UGH GRADfNG � •
ROUGH PlUM6lNG � FINISH GRADlNG
SHOWERffUB 7E5T POOL ELECTRIC
EXT. LATH/SIDlNG ; PC)OL FENCING
WALL INSULATI�N � • ; POQL FINAL - -_.__�
CEILING INSULATION � I OFF SITE IMPS. i
DRYWALL NAILING � r DEDICATIONS
SEWER ^ I FINAL ENG.
SEPTIC TANK LANDSGAPE/(RRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. � � F!RE DEPT. �tNAL
F(NAl HEATlNG I HEALTH DEP7. FfNAL _ ,
FiNA�ELECTRIC DEV. FEES PAID �
FINAL PLUMBING ! ENERGY ^
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