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1111A.III.A11 IIAI'.
CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
TE
ADDRESS SS 22- -DIQ..1Y1M3 �r TNAYA
APN LOT TRACT
OWNER
ADDRESSplampro1� r
CITY ZIP TEL
APPLICANT L• TEL. II
CONTRACT QRCk
ADDRESS_IZ r 1Tj C
CITY�n TIM C• ZIP19 ii2TEL. 2-b- W-5? ZIIC
ARCH61ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UDDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS Lt.
CENSE UW FOR THE FOLLOWNG REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS WOE: ANYCITYOR
COUNTY WHICH REOUIRESAPERMITTO CONSTRUCT,ALTER IMPROVE. DEMOUSH.OR REPAIRANY STRUC.
TURF, PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE -SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW (CHAPTER S ICOMMENCNG WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONSCODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SEC71ON 7071.6 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
O LAS 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. 70". SUSI-
NESS AND PROFESSIONS WOE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. MIO WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH NIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUILDING OR MPROVEMENTIS SOLD WITHIN ONE YEAROF COMPLE-
TION. THE OWNER-BUP DER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRAMNO WITH LICENSED CONTRACTORS
TD CONSTRUCT THE PROJECT (SEC. 704. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE UAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
TIMID CONTRACTS FOR 3— PROJECTS WITHA CONTRACTOMS) LICENSED PURSUANTTO THE CONTRAO
TORSUCENSELAW.).
❑ IAM EXEMPT UNDER SEC. B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
S (COMMENCING WITH SECTION 7000) OF ONISON S OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT. 2
LICENSE CUSS UC. NO. -&-1(J l Z--43
DATE CONTRACTOR
WORKERTCOMPENSATION DECLARATION f �3
1 HEREBYAFFIRM UNDER PENALTY OF PERURY ONE OF THE FOLLOWING DECLARATIDNS:
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY BECTON 3700 OF THE LABOR LODE. FOR THE PERFORMANCE
THE WORK FOR MICR THIS PERMIT 155 ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
3700 OF THE LABOR ODOE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. UY WORKERS' COMPEN ATION INSURANCE CARRIER AND POLICY MUMMER ARE:
CARRIER
POLIOYNUMBER
(THS BECTON NEED NOT BECOMt;ETFD OFTHE PERMIT IS MR ONE HUNDRED DOLLARS (N DM OR Lm%
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
CODE. I SHALL FORTHWITH COMPLY WITH THOSE PPROOVISIONS.�'(��,,
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS IS 100.000). N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
BECTON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. - - -
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3097•CN. C.I.
LENDERS NAME
LENDEFTS ADDRESS
1 CERTIFY THAT I HAVE REM IO
THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -ME ED PROPERTY FOR NSPECTIN PURPOSES.
PERMITTEE RI/
t/
agNATURE OF � OAiE
PRESS
FIRMLY
APPLICATIONr
PERMIT
P/C
DATE
NUMBER
9
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
EXPI
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
Lj
LLU ❑
SIDE
❑
PROPOSED USE
I I
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NO. DWEL, NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
WPalio(Deck
LL
POOVSpa,
ZRe
-Roof
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Commercial
M
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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LU
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE __
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE 0"�
'�
PRE -ALT FEE: LJ "
�-" '
TOTAL FEES
f
COMMENTS
RECPT. NO. PAID BY
VALjDATIQWV
WHITE—Department Copy. YELLOW—Finance Copy. PINK—Assessor Copy. GOLDENROD— Ile COW GREEN—Applicant's Copy
)
'OF DIAMOND'SAR','1,1:1".0'f717
PECTIORECORD
N
I01SETBACK -,., ' ` ` 1-17- ____7 1 'FLOOR JOIST
FTGS/FORMS/STEEL- FHA REONITS
ELECTRIC GROUfJtdH UNDER FLGOR.PUCT,
GROUND PLUMBING FLOOR CONDUIT UNDER
SLAB GRADE FIREPLACE'FOUNDATION
j
TEMP -POWER-- FIREPLACE BOND BEAM- -
WATER'SERVICE - 'mo HT. BOND BEAM
ROOF SHEATHING 8 Ft. BOND BEAM
FRAMINGIVENTILIATION FINAL: BOND -BEAM
ROOF COVER-..---- PRE -GRADING
ROUGH t4EATING GENdHING_
-ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING FINISH'GRADING
SHOWERITUB TEST' 'POOL! ELECTRIC R.
-EXT.'L.ATH,/SIDING'1_ _POOL FENCING
WALL INSULATIONPOOL FINAL
CEILING INSULATION OFF SITE IMPS.1'..;
DRYWALL NAILING DEDICATIONS.
SEWER - FINAL, ENG.
SEPTIC -TANK LANDSCAPE/IRRIG.:.-'
SEEP_PITJLL._.:____
; ONSITE
I
m PS.
GASAIR TEST-F1NAL ZONING
FINAL CONST: FIRS FIN
AL
FINAL -HEATING-----------,------ HEALTH DEPT INAL
FINAL'ELECTRIC DEV. FEES PAID
'FINAL: PLUMBING ENERGY
.. ............
EF_.
�COMMENTS,
L,
SEPTIC TANK -SIZE
(SEEP PIT/U SIZE
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