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, , CITY OF DIAMOND BAR ;
-- DEPARTMENT OF COMMiJNITY&DEYELOPMENT SERVICES MAY 0 91003
21660 E.Copley Drive Suite 190 �
(909)860-3195 Faa(909)861-3117 , PRE$$
����� BUII.DING PERMIT APPLICATION � FIRMLY
} JOBSITE ,Q�[� � +��D,�J. ���I f �` 3 DATE CATIO �—� C� NUMBEF#J"� #lC
� ADDRESS V V ►1(A_�� �
� ISSUE ",l TYPE OCC
APN LOT TRACT DATE ��`�� CONST. GROUP
¢ OWNER
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�` ADDRESS ZONING SETBACKS
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APPLICANT' TEL. SIDE/SIDE STREET RW ❑
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� ADDRESS ' PROPOSED USE
o CITY ZIP TEL.
� ARCH/ENG/
DESIGNER NO.DWEL. NO. /N ..
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� DESCRIPTION SQ.FC F P F AD EANAL ATION
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� I HEREBY AFFlRM UNDER PENALTV OF PERRIRV THAT I AM EXEMPT FAOM THE CONTRACTORS LI- G9fHgB/C9f�10h
CENSEUIWFORTHEFOLLOWPIOREASOH(SEC.7o37.58USIHESSMIDPROFESSIONSCOOE:ANYCIT'OR (n
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TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT WR SUCH PERMIT TO FlLE A SIGNED w
STATEMENf 7T1AT ME OR SHE IS LICENSED PURSUMlT TO 7HE PqOVISIONS OF THE CONTMCTORS LI�
� CENSE UW(CHAPTEH Y(COMMENdN(i WIT1 SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PoOVSpB -
FESSqNSCOD�ORTHATHEOR5HEI5E%EMPT7HEREFROMANDTHEBASISFORTHEALLEOEDIXEMP� �
TION.ANY VIOL�TION OF SECTION 7W1.6 BY ANV MPLICMIT FOR A PERMIT SUBJECTS TNE APPLICANT T0 Z Rg-Rpp}
� A CIVIL PENALTY OF NOT MORE T1AN FNE HUNDRED DOLURS(i600�.):
� ❑I,ASONMEROfTHEPROPER7V,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSA710N, 0 COmrtlBfCl01 . � � ,
WN.L DO THE WOPo(,M1D THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7W�,BUSI� J
N NE55 AND PqOFE55lON9 CODE THE COHTRACTOi15 UCENSE LAW DOES NOT APPLV TO AN OWNER OF � �
PROPERTV WFq BUM1DS OR IMPROVES THEREON,AND Nh10 DOES SUC/i WORK HIMSEIF OR HERSELF OR
� THROUGH HIS OR HER ONM EMPLOYEES,PROVIDED THAT SUCH MIPROVEMENTS ME NOT INTENDED OR m
L�1 OfFER W POR SALE IF.HOWEVER TME BULD W�OR BAPFOVEMBlT IS SOID WfT}GN ONE vEAR OFCOMRE-
Z ��TION,THE ONRIER-BUILDEfl yIILL HAVE THE BURDEN OF PROVfNO THAT HE OR SME DID NOT BUIID OR
� W VROVE FOR THE NRPOSE OF SALE).
{y� ❑4 ti+`ONRIER OF 7HE PROFERTY,AM IXCLUSNELV CONTMCTRIO W17H LICENSED CONTRACTORS
Q TO CONSTRUCT THE PRO.IECT(SEC.7oH,BUSINE9S AND PROFES310N5 CODE 7HE COHTRACTORS U- VBIUHII011 ADJ.AREA
� CENSE lAW OOES NO7MPlV TOAN OWNER OFA PROPERTY N?10 BUILDS OR IMPROVES hiEPEON,AND
W/qCONTMCTSFORSUqiPROJECTSWITHACONTMCTOR(S)LICENSEDPURSUANTTOTIECONTRAF pUANTITY DESCRIPTION FEE �
� TOHS LICENSE UW.).
0 O I AM IXEIAPT UNDER SEC. B.6 P.C.FOR 7HI5 REASON Q
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DATE OWNER U �
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F .LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIqM UNOER PEIUITV OF PERIUFY THAT I AM LICENSED UNDER VROVISIONS OF CHAPTEN � ' �
� Y(CO►IMENCUq WfTH SECTION 7000)OF DIVISION]OF THE BUSINESS AND PROFESSIONS CODE,AND Z '
X MY LICENSE t5 RI FULL fORCE M1D EFFECT. m
LLJ �
_ � LICENSE CUSS UC.NO. � �
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U DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION �
. � 1 HEREBV AFFlRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWfNO DECURATIONS: Z
�Z _I HAVE AND WILL MAINT/UN A CEHTIFlCATE OF CONSENT TO SELF-INSURE FOR NbRKERS' a '
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COMPENSATION,AS PROVIDED BV SECTION 37000F THE 1A80R CODE,fOR THE PERFORMANCE w
OF THE WORI(FOR WHlqi THI9 VERMIT IS ISSUED. �
_I HAVE M�WILL MAINTAW WORNERS'COMPENSATION INSURANCE,AS REW IRED BV SECTION
� 37o00F THE L�BOR CODE,FOR THE PERFORMMiCE OF THE WORK FOR WHICFI THIS PERMR IS � ��� '
� ISSUED.MY WORKERS'COAIPENSATION INSURANCE CARRIER AND POIICV NUMBEH ARE CONSTRUCTION
3 c�wPoea � PLAN FEVIEVJ
� °°ucrr�uueER ELECTRIC � '�
0 (IYCSSECInNNfIDNo78EWARLE7IDOFn�EPEPo.ffsFORONEVa1�[YiE000uARs�i�roloaLE55�. PLUMBING �1 /{ ]\ r
Z t CERTIFY THAT W hiE PERFORMANCE OF THE MIORN f-0R wHlqi THIS PERAIIT IS ISSUED,I MECHANICAL � 11 II 14 .i�
, (,�J SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE �^"
(/� � WORKERSCOMPENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOAIE INSPECTIONFEE
SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION77000FTHELABOR ��^ � �
cooE,i sru��FoarHvnn+coMv�r vntri nasE Paovisror�s. ISSUANCE �p�y a —.F+ C, n
p DAiE: � APFLICANT: �SMIP 4.j7't�.... ' 1/
� WAANINO:FNLURE TO SECURE WORKERS'COMPENSATION COVEMOE IS UNLNWFUL,AND SH�LL BE ENERGY P/C �T�h r viA nRn„,�
SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FRlES UP TO ONE HUNDRED THOUSAND {;"�x.If� �''i Q�J N?T
� DOLURS(i100.000),W/�DDITION TO THE C0.ST OF COMPENSATION,DAMA�ES AS PROVI�ED FOR IN ENERGY PERMIT "�G�A�y r. �/y'nj+�L�C
� SECTION 370E OF THE UBOR CODE,INTEREST,AND ATTORNEVS FEES. ' RETENTION FEE: JHr�+! y
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFlRM UNDER PENALTV OF PEFLIURV THAT THERE IS ACONSTAUCTION LENDIN�AOENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMI7 1S ISSUED(SEC.30W,GV.C.). ,
Z eWN �R
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� LENDEH'S NAME �
� LENDER'SADDRE55
� I CERTIFY THAT I HAVE READ THIS MPLICATION AND STATE THATTHE ABOVE WFORMATION IS CORAECT. TOTAL FE ES
W I A�HEE TO CAMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE UWS REUTIN(3 TO BUILDINO
� CONSTRUCTION,AND HEREBV AU7}IORIZE REPRESENTATIVES OF 1HI5 COUNTV TO ENTER UPON THE - - �
S� ABOVE�MENTIONED VROPERTV fOR INSPECTION PURPOSES. COMMENTS �
� �DR � JRY � . RHATT
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¢ PERMITTEE NAME(PWNn� � � �0
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� S � o�rE RECPT.N0. PAID BY VALIDATION
� WHITE-0epartment Copy,YELLOW--Finence CoPY�PINK—Assessa Copy,GOLDENRO ile Copy,GREEN—ApplicanYs Copy
��d���'-�;�°� Cll'Y �� CD��iViC)i�9fD [�A� ` •
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ELECTRIC GROUND UNQER FLOOR DUCT '� - : � �
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GROUND Pl.UM81NG UNDER FLOOR CUI�IpUIT' ', �g �� ��` ��r ?b ��_
,SLAB GRADE ' FIREP�:.A�E FQUt�DATION ; �� � '' '��--�
r'
TEMP POWER ' FIREPLACE BOND BEAM e � , ,� {_� ' „ '',� �
WATER SERVICE - MID HT. BOND BEAM
ROOF SHEATHING • ' • ' � 8 FT. BOND BEAM
FRAMINGNENTILIATION ', � � - FINAL BOND BEAM �
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ROQF COVFR � � PRE—GRADING �s:' .3-: • ' � + , �
ROUGN HEATING ' BENCH!(�� . +;. i� , .,, _ ;, .. ,:'
ROUGH EtECTRIC , " ROUGH GRADING � � ���' � '• -
t�OUGH PLUNI�INC FINISH GRADING
SHOWERtTUB TEST � POOL ELECTRIC
EX7. IATH/SIDING � - POOL FENCING
WA�L INSULATION POOL FINAL .
GEILiNG INSULATION OFF SITE IMPS,
DFIYWALL NAIUNG ' DEDICATIONS
���N�a FINAL ENG.
�SEPTIC TANK LANDSCAPE/IRRIG. �.
SEER PITIL.L. ON SITE IfViPS. �
GAS AIR TEST FINAL ZONING ,
Fl1vAL CONS7. FIRE DEPT. FIFJAL �
FIiJ:�L NEATING HEALTH DEPT. FtNAL
FiNAL ELECTRIC DEV. FEES PAID
f �_;:�!/��PLUMBING ENERGY
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� CONlMENTS _ _ . _ _ _ _ _ ._ . _ . ... . . .
SEPTIC TAf�IK SIZE
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PFCI�MAi1CJN '
` COUNTY SANITATION DISTRICTS
I SOLID W�STE NANAGEMEN
I OF LOS ANGELES COUNTY
t 955 Workman Mill Road / Room 130 / Whittier, California CHARLES W. CARRY I,
Mailing Address: P.O. 8ox 4998, Whittier, California 90607 Chiei Engineer and Generai Manager ,
Telephone: (3t0) 699-7411 / From Los Angeles (213) 685-5217
Hours: 7:00 a.m. - 4:30 p.m. Mon. - Thurs.
7:00 a.m. - 3:30 p.m. Fri. �Account No.:
SEWERAGE SYSTEM CONNECTION FEE b'st�"�t No.: � �
Complete ltems 1 through 10—PLEASE TYPE OR PR/NT
Date: � � I � � �
(MONTH) (DAV) (�'EAA)
1. Property Owner `-1�_I�``�m Q S R �"'1 � T ���--�—���
2. Facility Name
3. Address of Property_
� a� ���� ��� �i���a� �i 6�
�sra En (arv� �' lsrnrel cziv� .
Major Cross Sireets �D<:.��I G�(� Thomas Guide Page
4. Cornad._ �-� 'l��D� Phone Number. ( ��) v�� '— �.9_I_y
5. Mailing Address_���C l�� UP 1��� � • 1 �� tJ����
(IF DIFFERENT FR0�.1/BOVE) (STf7EEn (CITY) (STATE) (Z�P)
6. County Assessor Map Book, Page, and Parcel Number. lv�� - LI.�Lv� � I��P� �
�. Structure is: � Proposed ❑ Existing, Date of Construction "��\ — q 1
8. User Category and Units of Usage: (Check the appropriate box and provide the applicable in%rmation)
a. Residential: I� Single Family Home(s)
Tract t1 ZZ.. Lots 'Z- ► Number of Units:
❑ Du lex ❑ Tri lex ❑ Four lex ► Number:
❑ Five Units or More - ► Number of Units:
❑ Mobile Home Park ► Number of S aces:
❑ Condominium ► Number of Units:
b. Commercial: ❑ Hotel/Motel ► Number of Rooms:
❑ Convalescent Hos ital/Home for the A ed ► Number of Beds:
❑ Other S eci ► Im rovement Square Foota e:
c. Institutional: ❑ Colle e/Universit ► Number of Students: .
❑ Private School � Im rovement S uare Foota e:
❑ Church ► Im rovement S uare Foota e:
d. Industrial: ❑ All Categories ► All industrial dischargers must obtain a permit for
industrial wastewater discharge.
s. In order to 'process this application a complete set of architectural blue prints must be submitted.
This is not required for conversion from septic tank to sewer connection.
tio. ! ce ify that t e information provided in this application is true and correct to the best of my knowfedge.
O OWNER
' ._-� ��� � � � �AGENT FOR OWNER
� NAT RE) (DATE)
Please pay by check or money order only.(Cash will not be accepted.)
Make checks payable to: COUNTY SANITATION DISTFiICTS OF LOS ANGELES COUNTY.
Retumed checks will be subject to a penalTy. , .
FEE CALCULATION FOR RESIDENTIAL, COMMERCIAL, AND INSTITUTIONAL CATEGORIES
X $ �. �O = $ /�/ D��
(� C� /� �
Number f Units of Usage Connection Fee Per Unit of Usage Co�nection Fee
SPECIAL CREDITS (Only if Applicable)
� DEMOLITION CREDIT' 'In order to receive credit,proof of demolition �
or former use must be submitted with your _ $
❑ CHANGF ��l USF.CREDIT� _ '_ . ?r.nitf`atinnlg,�,_(lmm�lifie+n_Q�....;.r �.;..,...,� . _ , __ . . . - -
`' � AD VA�ORE�VI TAX CREDIT plans). � � ^ I+ I
Annexation Date I
$ /�)
(If Less Than Zero, Enter Zero) . �(/
onnection Fee Due.
.
.-�---� (For Dislricts'Use Only) G� '''"-'' -- ` �
FEE PAY T RECENED: ° Processed by � '� -��` '
I From: D.C. . D Yes. No Approved by:
D =�. �- ,���.
`.� .� ��''=°`n: P
p.� ��� � � � � � 'l� ``�� d �' ����
I A m o un t: $ Ck. No. Permit No.: Date:
, . '
, ,-,�;.,,��_�vv.c,aHRY
' WHITE COPY—CQUNTY SA`:ITATICN CISTRICTS GF LOS ANGELES COUNTY C�iIEF G7�!(;(NEL=T,&GFN.MGR.
YELLOW COPY—BUIIDING DEPARTMENT
PINK COPY—APPLICANT
DO NOT SEPARATE .
. . . . ' . . ' • , � . � . , . , . ' I
' .. � . . ' , r .�'f ij,.
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, , ' WALNUT VALLEY iJNIF'IED SCHOOL DISTRICT
880 SOUTH LEMON AVENUE WALNUT CA 91789 �
CERTIFICATE OF COMPLIANCE
With Fee Fro�isions of
Government Code Section 65996
�P+ cnRs '�HA.I"'C
DEVELOPER/OWNER IU�w�S�� �NS�C�
ADDRESS —�QX �O R�1 Signature of Ap c t
CITY/ZIP v p�Asva 9�7 8 S—�d 8 $ The person si ' esents that he/she is authorized
TELEPHONE �{pq- ACnI— 9n1� to sign on behalf of the owner/developer and that the
information provided is true and accurate to the best of
his/her knowledge.
NEW OT ADD�SS USE OF BUILDING TOTA SQ. FT.
. I ��(P I,�'►�,a.vw8vc� wo�,� l�( �,�!fZ �
Residential/Commercial/Industrial
City
HOME IMPROVEMENT OR REMODELING PROJECT
ADDRESS DESCRIPTION TOTAL SQ. FT.
Diamond Bar Walnut (Bedroom, F 'y ., tchen, etc. �
Signature of Superintendent of Buildings Date � ' ro �
TO BE COMPLETED BY HOOL DISTRICT
FEE SCHEDULE: The development fees levied by the Walnut Vall Unified TOTAL FEES DUE
School District under provision of Government Code §65995 $ �3 �j0� �Q
are: (EFF. 8/17/98) Residential Development $1.93/sq. ft. Receipt# ,J' �
Commercial/Industrial $0.31/sq. ft. Date
Fees are assessed on TOTAL square footage "living space" of ALL new or remodeling construct on ojects OVER 500 sq. feet
(eluninating garage or uncovered patio).
!/ This is to certify that all fees due to the Walnut Valley Unified School District under provision of Government Code Section
65995 have been received and a building permit may be issued. .
This is to certify that the above described development has been determined to be EXEMPT from the development fees of
Government Code Section 65995 and a building permit may be issued. ,� •,,:��
r---.
Exemption Justification: PROJECT IS SOO OR LESS SQUARE FEET L �'��
OTHER c - --,,,- ,
.� :��-. '._
r-�
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.. ' „�.'f� � + f_��T3
`� f"'.�1.-�
''C�
emon Medeiros c'�
Assistant Superintendent • � � �-'"
Fiscal and Facilities Management
1/87 Rev. 2/88; 6/88; 8/89; 1/90; 8/90; 10/90; 8/92; 6/93; 11/93; 8/94; 6/96; 1/97; 8/98 �
PLEASE SEE NOTICE OF 90-DAY PERIOD FOR PROTEST OF FEES ON REVERSE SIDE
� •
N�TICE OF 90-DAY PERIOD FOR PROTEST �F FEES
Section 66020 of the Government Code enacted as Assembly Bill 3091, set forth as Chapter 549,
Statutes of the State of California, 1996 effective January 1, i997, requires that this school
district provide a written notice to the project applicant at the ti.me of payment of school fees,
mitigation payments or other exactions. This notice is to advise you that any protest in regard
. to such amounts or the validity thereof in accordance with Section 66020 of the Government
Code and other applicable law, commences with such payment or performance or any other
requirement as described in Section 66020 of the Government Code. Additionally, this notice
advises that the protest thereof must occur within 90 calendar days thereafter.
,
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--� DEPARTMENT OF COMMUTTITY&DEVELOPMENT SERVICES
_ w 21660 E.Copley Drive Suite 190 MAY � 9 �^�3
(909)86Q3195 Fax(909)861-3117 . ����- PRESS
���', BUII.DING PERMIT APPLICATION FIRMLY
I �� JOBSITE l � DATE CATION (� NUMB R ����� g/C I
ADDRESS (!� �/�"r/�� D �N�� �
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ADDRESS � X /O� �-- �
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� DESIGNER NO.DWEL. NO. NO.
� ADDRESS UNITS STORIES BEDROOMS
CITY ZIP TEL.
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM ��
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� 1 HEREBY AFFiiW UNDEfi PENALTV OF PE0.0.1RY TFIA7 I AM E%EMPT FHOM 7HE CONTMC70RS ll- Gef89B/CBfpOR �(/W ` —
CENSE UW FOR THE FOILOWMO REASON(SEC.703t.5 BUSINESSAND PROFESSIONS CODE:M7Y CITYOR (n
COUHTYNMIpiREOUIRESAPERMRTOCONSTRUCT,ALTER�PROVE,DEMOLISH.ORREVNRANVSTRUG W PgIIO/DBCK
TURE,VRIOR TO RS ISSUANCE,PL50 REOUIHES THE APPLICMIT FOR SUCH PERMIT 70 FILE A SIONED w
STATEMENT h1AT HE OR SHE IS LICENSE�WRSUANT TO THE PROVISIONS OF THE CONTRACTORS L4
� CENSE UW(CHAFTER Y(COMMENGNO WITH SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PRO� � PooUSpa
FESSqNSCODE)ORi71ATHEORSHEI3E%EMPTTHEREFROMANOTHEBASISFOR7HEALLEOEDE%EMP- (3
TION.ANVVpU�T10NOFSECTION70J1:6BVAHVMPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A CML PElULT'OF NOT MORE 7HAN FfVE HUN�RED DOLLAHS(i5oo).): �
� ❑I,ASOVMEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESIISTHEIRSOLECOMPENSATqN, O COrtIfi10/CIBI --
WILL DO THE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7041,BU51- J
" N HE53 MA PqOFE5S10N5 CODE:TME CONTRACTORs LICENSE LAw�OES NOT APFLv 70 AN OWNER OF �
PROPEiRV VM110 BULLDS OR 41PROVES THEREON,AND WHO DOES SUCH WOPK HIMSELF OR HERSELF OR
� 7HROUGH HIS OR HER OWH FJAPLOYEES,VROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
� OFFERmFORSALEIF,HON�EVER7ME8ULOWOORIMPROVEMBITIS50LDWRHMONEYEAROFCOMPLE-
Z �`TION,iHE ONVNER-BUIIDER WILL HAVE THE BURDEN OF PROVWO THAT HE OR SME DID HOT BUIID OR
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