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CITY OF DIAMOND BAR �x� `�
- " DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
, � (909)860-3195 Faz(909)861-3117 PRESS
������'� BUILDING PERMIT APPLICATION FIRM I
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APN L T TRACT DATE CONST. GROUP
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v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I NER�Y IIFFlRM UNDER PENALTY OF PEFi.IURV THAT I AM EXEMPT FROM THE CONTRACTORS L4 �GflffiQO/CBfPOh
11J CENSEIAWFORTHEFOLlOWR10REASON(SEC.70]1.6BUSINESSANDPROFESSIONSCODE:ANVGTYOH (n
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Z TURE.PRqR TO RS 159UANCE.AL50 REW IRES 7HE APPIICANT FOR SUCH PERMIT TO FILE A SIONED w PatlO/DBCk
STATEMENT TFIAT HE OR SHE IS LICENSED PURSUMfT TO 7HE PROVISIONS OF 7HE CONTAAC70RS LI-
� C@!SE UW(CHAPTER G(COMMENCWO WITI SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � FooUSpa �
FESSqNS OODE)OR THATHE OR SHE IS EJ(EMP77MEREFROM AND THE BASIS f-0R THEALLE�ED EXEMP- (�
TION.ANYVIOlAT10HOFSECTION7W1.68YANYAPPUCAHTFOHAPEfiAIITSU&IECTSTHEMPIICMlTTO Z Re-Roof
� A CML PENALTV OF NOT MORE 7HAN FNE HUNDRED DOILAHS(fb0o)J:
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WILL DO THE WORI(AND 7HE STRUCNHE IS NOT INTENDED ON OFFERED FOR S/�LE(SEC.7aI,BUSF �J
� NESS AND PROFESSIONS CODE:TNE COHTRAC70R,4 LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPEqTY WF10 BULD90H MPROVES 7HEREON,Ml�MM110 DOES SUCH WORI(HI�ISELFOR HERSELF OR
� TIROUGH MS OR HER OWN EMPLOYEES.PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
QOFFERmFORSALEIF.HOM/EVER71tEBUIL.DWOORWPROVEM@RISSOLDWI7HWONEVEAROFCOMPLE
Z �'TqN,THE OWNER�UILDER WILL HAVE THE BURDEN OF PROVP/O THAT HE OR SHE DID NO7 BUILD OR
� IMPROVE FOR 7NE PUHPOSE OF SALE). .
� ❑4�OWNEROFTHEPROPEHTY,AME%CLUSNELYCONTMCTW�N7T51UCENSEDCOMMC70R5
TO CONSTHUCT h1E PRQIECT(SEC.7041,BUSINE55 MID PROFESSIONS CODE:THE CONTMCTORS LI- VBIIlelI0f1 AOJ.AREA
CENbE UW DOES NO7APPLV TOAN OWNER OF A PROPERTV WFq BUILDS OH IMPROVES THEREON,AND
� W/pCONTMCTSFORbUCHPRQIECTSWITiACONTMCTOR(5)LICENSmPURSUAHTTOTHECONTMP OUANTITY DESCRIPTION FEE �
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❑I AM D(EMPT UNDER SEC. B.6 P.C.FOR 7HIS REASON Q
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DA7E OWNER � �
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LICENSED CONTRACTORS DECLARATION �
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I HEREBV AFFIRM UNDER PENALTY OF PE0.IURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � C
� Y(COMYENCWO WITH SECTqN 7000)OF ONISION 9 OF THE BUSINESS AND PFOFESSIONS CODE,AND Z J �
��� MY LICENSE IS Pl FULL FORCE AND EFFEC7. m
� LICENSE SS ���1�/� LIC.NO. �� ` .S �
V DATE ��S�f/ CONTRACTOR d
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� WORKERS'COMPENSATION OECLARATION Q
NI HEREBV PFFlAAI UNDER PENALTV OF PERIUM ONE OF THE FOLLOWINO DECIARATIONS: Z
� _I HAVE AND WILL MAMTNN A CEHTIFICATE OF CONSEM TO SELHNSURE f-0R WORKERS' _
Q COMPENSATION,AS PROVIDm BV SECTION 37000F THE UBOR CODE.FOR TNE PER W qMANCE W
O OF THE WORK FOR WFIK?i hIIS PEqM1T IS ISSUED. �
� �I HAVE AND WILL MAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 3�o00F iHE LABOR CODE.PoR TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS
ISSUED.MY NV E /CPE�NSATq/1��IN/�11RANCE CMRIER AND POLICY NUMBER ME: CONSTRUCTION
jCAHRIER ��`� O• � PLAN REVIEW
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� (nassEC�qNr+�wiBEoa1.�LE�IDOFnEPEfAffsFbRor+EMx�Dt+�oallRsR�w)oaLFss1 PLUMBING �
Z 1 CERTIFV THAT IN THE PERfORMANCE OF THE N'ORI(FOR WHlpi THIS PEFUIIT IS ISSUED,1 MECHANICAL
(•} SHALL NOT EMpLOV ANY PERSON IN ANY MMINER 50 AS TO BECOME SU&IECT TO THE
� MqPo(ENS'COMPENSATION UWS OF CALIFORNIA,PND AOREE THAT IF I SFIOULD BECOME INSPECTION FEE
S SU&IECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SECTION 3700 OF THE 1A80R
e,i sw�u ronn+Nnn+coMa�r Mnn+nasE a iswNs. ISSUANCE
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p DATE:��e�r APPLICANT: SMIP
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� WAANINU:FAILURE TO SECURE WORKERS'COMPENSATlON COVERAGE IS UNUWFUL,AND SFIALL BE
�y SUAIECTANEMPLOVERTOCAIMWALVENALTIESANDCIVILFWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �
DOILARS(floo,000).IN ADDITION TO THE COST OF COMPENSATION,DM/AOES AS PROVIDED FOR IN
� � SECTION 370!OF hiE LABOR CODE,INTEREST,AND ATTOFiNEYS FEES. ' RETENTION FEE:
� CONSTRUCTION LENDING AGENCY PRE•ALT FEE: �
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDMO AOENCV
FOR TME PERFOHIAANCE OF hiE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30G7,CIV.C.). .
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� LENOER'SNAME .
H LENDER'SADDRESS
� I CERTIFY THAT I MAVE READ THIS MPLICATqN AND STATE THAT 7HE A80VE INFORMATqN IS OORHECT. TOTAL FEES O
W I AGREE TO COMPLV WITH ALL CfTY AND COUNTY OqDWANCES AND STATE UWS RELATINO TO BUILDINO
' � CONSTRUC710N,M70 HEREBY AUT110RRE REPRESEN7A7NES OF THIS COUN7Y 70 ENTER UPON THE µ` � /!►�//�^ ,A\ �/� //�� /�J�[��
Z ABOVE�MEHTIONED PROPER7Y FOR INSPEC710N PURP0.5ES. COMMENTS�✓�+ V VI/I SJ��J W�Y J G7�
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� RECPT.NO. PAID BY VALIDATION
WHITE—DepaAme�t Copy.YELLOW—Finence Copy,PINK—Assessar Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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ROUGH PLUNIBING - FINISH GRADING
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CEILIIVG INSULATION OFF 51TE IMPS.
DRYWALI.NAILIf�G DEDICATIONS
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SEEP PIT/L.L.. ON SITE IMPS.
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