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� CITY OF DIAMOND BAR , EXPIRED
DEPARTMENT OF COMMUNITY&DEYELOPMENT SERVICES
Zi�o E.coPiey na�e s�c�i90 MAY 0 9 2003
(909)860.3195 Fax(909)861-3117 PRES$
���TM'� BUII.DING PERMIT APPLICATION FIRMLY
o� JOBSITE � �� r I�f p n/��_�n ��� I L APPUCq�N��I� NUMB R #/C
ADDRESS �O �/��d !�C7 {/ �^' DATE /
$ ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER
LL AODRESS � ZONING SETBACKS
Z CITY • ZIP TEL. ' 7 REART RW ❑
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� TURF,CRpR TO ITS ISSUANCE ALSO REW IRES THE APPIICANT FOFi SUCH PERMR TO FILE A SIONED w �
STATEMENf 7HAT HE OR SHE IS LICENSED PURSUMlT TO THE PROVISIONS OF hiE CONTRACTOpS Ll-
� CENSE UW(CIUPTER G(COMMENCWO WITH SECTION 7000)OF DMSION 3 OF THE BUSINE53 AND PRO- � POOVSpB
FES910N5 COD�OF THAT HE Of15HE IS EXEMPTTIEREFROAI AND THE BASIS FOR THE ALLEOED E%EMP- (�
TION.AHYVIOLATqNOFSECfION7031.6BVANVMPLICANTFORAPERMITSUBJECTS�TNEMPLIGNTTO Z Re-Raot
� A CIVIL PENALTY OF NO7 MOHE THAN FNE HUNDRE�DOLURS(i5o0).): .
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N NESS NID PROFESSIONS COOE THE COHTRACTORS UCENSE UW DOES NOT APPLV TO AN OWNER OF �
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' � Q THROUGHWSORHEROMMEMPLOVEES,PROVIDEDTHATSUCHWPROVEMENTSARENOTINTENDmOR .
� OFFERmFDRSALEIF,iIOWEYERTMEBUILDINOORIMPROVEMBdTISSOLDWITWNONEVEMOFCOMPLE•
� �'TION.THE OV/NER�BUILDER N1LL HAVE THE BURDEN OF PROVIMO THAT ME OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE�.
� ❑I,A90WNEROFTHEPROPEHTY.AMEXCIUSIVELYCONTRACfINOWI7HUCENSEDCONTRACTORS
TO CONSTRUCT 7HE PRQIECT(SEC.7041,BUSINESS AND PROFESSIONS COi)E TNE CONTRAC70R5 LI� V91U9110f1 ADJ.AREA
CEHSE UW DOES NOTMP�Y TO AN OWNER OF A PROPERTV WFIO BUILDS OR IMPROVES THERC-0N,AND
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❑I AM E%EAIPT UNDER SEC. 8.!P.C.FOR 7HIS REASON
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� DATE OWNER
� LICENSED CONTRACTORS DECLARATION �
� 1 HEREBV AFFIRM IMDER PENALTV OF PERIURV TiAT 1 AM LICENSED UNDER PROVISIONS OF CHAP7ER �
� Y(COMMENCWO WITM SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSKKJS CODE,AN� Z �
X MY LICENSE IS P!FIAl FORCE AND EFFECT..
� UCENSE CU � IIC.NO. � `'`�' ' j �T� �
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� I HEREBYAFFUiAI UNDER PENALTV OF PERAIRV ONE OF THE FOLLOW WO DECLARAT l�� .
O _I HAVE AND YALL MAINTAIN A CEfiTIFlCATE OF CONSENT TO SELF-INSURE FOR VA NERS' � � , , , �
Q COMVENSATION.AS PROVIDED BV SECTION 7/0o OF TME LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
�
W I MAVE AND WILL MAINTAW WORKER9'COMPENSATION INSURANCE,AS REOUIRED BV SECTqN
Q3700 OF THE LABOR CADE,FOfl THE PERFOHMANCE OF 1HE WOIiK FOR WHICH 7NI5 PERMIT I
� tSSUED.MV WORKERS'COMPENSA SUFUNCE CARRIER AND POLICV MIMBER ARE: CONSTRUCTION
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Z I CERTIFY TNAT IN THE PERFORMANCE OF THE WORK WR NM111CH THIS PERMIT IS ISSUED,I MECHANICA�
(f SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
(n WORKERS'COMPENSATqNUW50FCALIFORNIA,ANDAOFEETHATIFISHOULDBECOME INSPECTIONFEE
SU&lEC7 TO THE WORKERS COMPENSATION PROVISIONS Of SECTION 370o OF TME IABOR
OcooE,i sr�u1 wan+winr coMv�v vn ho 6 r isrons. ISSUANCE i, �
p DATE:�� APPLICANT:,�� (�� SMIP ` (��}
' J WARNINO:FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL,M!D SHAIL BE ENERGY P/C 1 1"1llC
� SU&IECTANEMPLOVERTOCRIMWALPENN.TIESANDpVI�FINESUPTOONENUNDREDTH(H15N7D ENERGYPERMIT
� DOLLARS(i100.000).IN ADDITION TO hiE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN -
� SECTION 37aL OF T1E l./�BOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: tA
pw.. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ����� v %� ���+�
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AOENCV ��T�;� �"� - -' 't jl"t[�,� ' '
�Z FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30W,CIV.C.). -., --.._ ._._,_ .� -- - - . . .
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' � LENDER'SNM1E '- •.^ .
� LENOER'SADDRESS k
� I CERTIFY THAT I HAVE READ THIS MPLICATqN AND STATE THAT 7HE ABOVE WFOWJATqN IS CARRECT. TOTAL FE ES -" � L�
w 1 AOHEE TO COMPLV N77H ALL CITY AND COUNTY ORDINANCES ANO STATE UWS RELATMq TO BUILDINO ' �� �
� CONSTRUCTION,AND HEREBV AUTTqRIZE REPRESENTATNES OF TFIIS CIXINTV TO ENTER UPON 7HE � ' . . � � �
Z /�BOVE-MENT%7NED PFOPERTY FOR INSPECTION PURP0.SE5. ' � ,
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WHITE—Depertment Copy,YELLOW—Finence Copy,PINK—Assesaor Copy,GOLDENROP�iie Copy,GREEN—Applicant's Copy
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SIAB GRADE FIREPLACE FOUNDATION , �
TEMP POWER FIREPLACE BOND BEAM • '
WATER SERVICE MIQ HT. BOND BEAM �
ROOF SHEATHING 8 FT. BOND BEAM � - � '
FRAMINGNENTILIATION FINAL BOND BEAM ' '
ROOF COVER � PRE-GRADlNG
ROUGH t�iERT1NG BENCHING' '
ROUGH E�ECTRIC ROUGH GRADING
ROUGH PLUNIBING (� FINISH GRADiNG
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL WSULATION / POOL FINAL
CEILING INSULATION - OFF SITE IMPS.
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