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CITY OF DIAMOND BAR ��� . � �
--�"��— DEPARTA�NT OF COMMUNITY&DEVELOPMENT SERVIC���
, a, 21825 Copley Drive,Diamond Bar,CA 91765 �1�.,,.�� � �'���
(909)839-7020 Fax(909)861-3117 Building Inspection Hotti���9���3 11L7����iORP��J'1C��
�'""� BUII..DING PERMIT APPLICATION R�uiP�d priOr to Firf�RMLY
� JOBSITE .// �" (b
� ¢ ADDRESS �d.7-� P'���►��Ck- �I. 9�7c¢S APPLICATION O/Il�/`� PE e ��_
p DATE S � NUMBER=^L���� #
� APN LOT TRACT D TEE s I �O �13 CONST. �`-'Y"""`" �C�
p OWNER T•L!C.. Ld1-yV E GROUP
o ADDRESS /O � OGL' ZONING SETBACKS
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o APPLICANT C.G�..� L=e..�G.w�srw� TEL. � 'f) 40�1 REAR �
zd SIDE/SIDE STREET RW p
� CONTRACTOR ►''��Conns�ck �9t/ SIDE �
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a ADDRESS NO.DWEL. NO. NO.
� C� ZIP TEL. UNITS B�'C STORIES O�� BEDROOMS
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� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLAAATION
p SFR/ADD/REM
� I HEREBV AFFlRM UNDER oENALTY OF PERRIRV THAT 1 AM EXEMPT FR04 TNE CONTRACTORS lF Garage/Carport
W CENSEUWFORTHEFOLLOWINOREASON(SEC.703t.58USWESSMlDVROFESSqNSCODE:ANYCI7YOR (n
ZCOUNTYWHICHREOUIRESAPERMRTOCONST�RUCT,ALTER,IMPROVE,DEI.IOLISH,ORREPNRANYSTRUG W PBUO/DBCI( �
W NRE,PRIOR TO RS SSUANCE,AL50 REpUTAES 7HE APPLICANT FOR SUCN VERMIT TO FILE A SIONED W
� STATEMENf THAT HE OR SHE IS UCENSED WRSUMIT TO THE PqOVI510N3 OF THE CONTRACTOH3 LF
� CENSE UW(p1APTER Y(COMMENCWO WITH SECTION 7000)OF DIVISION 9 OF THE BUSINESS AND PRO- � PooUSpa
^ FESSqNSCOD�OR7IUTHEOF5HEISIXEMPTTHEREFROMANDTHEBA515FORTHEALIEOEDE%EMP•
V 7�ON.ANYVIDLATIONOFSEC710N703t.5BYANVAPPLICANTFORAPERMRSUBJECTSTHEAPPIICANTTO Z �
� A CML PENALTY OF NOT MORE THAN FNE MUNORED OOl1M5({Soo).r
� ❑4�OMMEROFTHEPROPEHTV,ORMYEAIVLOVEESWITNWAOESASiHEIRSO1.ECpMPENSATION, � COfI1RI0�Ci81
Z NiM1.L DO THE WORK,AND THE STRUCTURE IS NO7 IMENDED OH OFFERED FOR SALE(SEC.�7oN,BU54 J "
� NE55 AND PROFESSIONS CppE THE CONTRACTORS IICENSE UW DOES NOT MPLY TO AN OWNER OF �
P{�PEHfY WFIO BUILDS OR W PROVES 7HEREON,AND WHO DOES SUpi WORK HIMSELF OR HERSELF OR
w THpOUGH NIS OR HER ONM EMPLOVEES,PROVIDED THAT SUpi IMPROVEMENTS ARE NOT IMENDED OR m
Q OFFEREDFORSALE�F.HOWEVERTMEWaDINGORIMPqOVEMENTI550LDWlTFqNONEVEAROFCpNpLE-
Z TION,THE OWNEREUILDER WILL HAVE 7HE BUROEN OF PROVIN6 THAT HE�OR SHE DID NOT BUILD OR
� GIPROVE FOR THE PURPOSE OF SALE} �
W ❑4ASOWNEROFTHEPROPEHIY.AMEXCIUSNELVCONTMCTW(iYVRHLICENSEDCONTRACTORS
[[ TO CONSTRUCi 7}{E PRQIECT(SEC.7011,BUSINESS AND PROFESSIONS CODE THE CANfRACTONS U- V81Ua�IOf1 qp�.qpEq
L11 CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTYNM1iOBUI�p50RIMPROVESTHEREON,ANO
� NM1iOCOH�RACTSFOq5UCi/PHOJECTSWITHACONT{UCTOR(S)LICENSEDPURSUANTTOTNECONTiUG pUANTITY DESCRIPTION FEE
Y TORS 110EN5E UW.).
� ❑I AM E%EMPT UNDER SEC. B,t P.C.FOR THIS qEASpN �
� U
� DATE oNMER F�- �
� LICENSED CONTRACTORS DECLARATION W
� 1 HEREBY AFFIRAI UNDER PENALTV OF PERHIRY THAT I AM LICENSED UNDER VROVISIONS OF CFiAPTER �
� B�COMMENCIN(i WITH SEC710N 7000)OF OtVI510N 7 OF TME WSINE55 AND PROFESSIONS CODE,AND Z
� W IICENSE IS Pl FULL FORCE AND EFFECT. m
� LICENSE CLASS C��I � LIC.NO. � •�/���� � .
V DATE ,2�I O�I� CONTRACTOR M��,d1C �L d .
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� WORKERS'COMPENSATION DECLARATION � �
N I HEREBV AFFIRM IMDER PENALTY OF 7ERIUHY ONE OF iNE FOLLOWWG DEG.ARATIONS: �
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Z� _IHAVEANDWILL1dA1NTNNACERT�FICATEOFCONSENTTOSEIF-INSUREFORWORKERS' a
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CON7ENSATqN,AS PROVIDED BY SEGTION 370o OF THE UBOR CODE,FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w _1 HAVE AND WILL MAPfTAIN WORNERS'COMPENSA710N INSURANCE,AS REOUIRED BV SECTION
Q 37000F TNE LABOR COOE,FOR THE PERFORMMICE OF THE WOR1C FOR NT11CH 7HI5 PERMIT IS
ISSUED.MV NO ERS'COMPENSATqN INSU CARqIER AND POI.ICY NUMBER ARE: CONSTRUCTION `��� � ��
> CARRIER �µ�a�c a..� �a�c�. PLAN REVIEW
� P«���aEA I�sC' 4 a r�o S�/ o�a—
� � ELECTRIC
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Z �CER7IFY THA7 1N THE PERFORMANCE OF THE VYOPo(FOR WHIp17N15 FER/AIT 45 ISSUED.I MECHANICAL
C} SHALL NOT EAAF�OV ANY PERSON IN ANV YANNEfi 50 AS 70 BECOtdE SU&IECT TO THE
(n WORKERS'CAMPENSATpN LAWS OF CALIFOW�11 AND,AOREE THAT IF I S/iDULU BECOME INSPECTION FEE
S SUBIECTTOTHEWORI(ERS'COA/PENSATIONPROVISIONSOFSECTION37000FTHElABOR � , ��
, cooe sHut FontHwina caapi.v w�nf n�osE Pao4isar�s. ISSUANCE
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p DATE � APPLICANT: li�w r�i1�'� �SMIP ���
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J WARNW6:FAILURETOSECUREWONCERSGOA/GENSATIONCOVERAGEISUNLAWFUL,M/DSHALLBE ENERGYP/C �
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�y SUaIECT AN EMPLOYER TO CRIAIPIAL PENALTIES AND CML FWES UP TOONE HUNDRED TFKKISAND ENERGY PERMIT
DOLLARS(lt0o,oao),W ADDITION 707HE C0.S7 OF COMPENSATION,DAMAGES AS PROV�ED FOR W
J SECTION 370!Of 7HE LABOR CODE.WTEREST,AND ATTOfWEV'S FEES.
w RETENTION FEE: O�• O�j
O . CONSTRUCTION LENDING AGENCY PRE-ALT FE�E+:
Q 1 HEREBY AFFIRM UNDER PENALTY OF PERAIRY THAT THERE IS A CONSTRUCTION LENDINO A6ENCY �S�\ 1 � OO
� FOR THE PERFORMANCE OF THE WORK FOR WHIp1 THIS FERMR IS ISSUED(SEC.30W,CIV.C.). -
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� LENDERS NAME
� LENDER'SADDRESS
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w ICERTIFYTHATIHAVEREAD.THISAPPLICATIONMIDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES O�('�� ��
� I AGREE TO COMP�Y WfTH/�LL C/TV AND COUNTV ORDWANCES AND STATE UWS RELATiNO TO BUO.DIN(i
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF T}IIS COUNTV TO ENTER UPON THE
Z ABOVE-MEMqNED PROPERTY FOR INSPEC710N PURPOSES. COMMENTS
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m PERM E NAME(P .
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� s NATURE OF FERMfTf TE qECPT.NO. �SO L�� pAID BY �����}
� VALIDATION
WHITE—Deperlmant Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—Ftle Copy,6REEN—ApplicanYs Copy
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SET BACK -_ �------y--- I FLOOR J01ST 1
FTGSlFOR�v9S/STECL j --__�� FNf�F�EC2h1TS ------�---- --� � —
ELECTRIC GRbUND � ; � UNdER FLOQR DUCT ;
GROUND PLUMBENG -� , � �UNC7ER FLC30R CUNDUIT�—
---_ ___
SLAB GRADE-------,----_-___�_.__----- _...- ---- _---------- ------ --�---- ------- -----....---.—_....----._...--
_i__ ' FIREFLACE FOUNDATlON �
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7EMP POV'JER ; -�---------- -- -------'
--,._�_..._._...-----------_,__------�-----------. -----_.._...._.__.. i FIREPLACE 80NQ BEAM i ; -----
WATER SERVICE ! s rMID HT BOND BEAM —�---------------------------
RQQF SHEATHING � � � _ i 8 FT. BOND BEAh.4 _� ±
FRAMINGNENTILRTION ' ; ' �FfP�AL 8CJt4D BER�� ; �
ROt?F Ct3VER ; ' PRE-GRADiNG
ROG'GH HEATING ; ;BEI�iCH1NCa �
RaUGH ELECTRlC � � �ROUGH GRADWG '
ROUGH PL��MBING ! + _� �Fih�ESH C7RAQIRG '
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SNOWERi�'UB TEST 1 _:_. �POOL ELECTRIC __..�_ _ _J--._..._^_
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EXT. LATH!SIDING i POOL FENCENG i
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OFF SiTE IE�'{PS. i ,
D R`f WALL NAI LI i�G i � ----------------�------,�------- - --
, � DEDICATlONS ��
SEWER � __._�_____ __ �INA�ENG, i
SEPTIC TANK E � • �LAi�GSCAPE/iRRIG.
SEEP PITI�.L. i i � � � rON SITE IMPS. � �
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GAS A!R TEST � i FIRAL ZC?hliNG ;
FINr�L 6f't�T. �' I!� '� /� � FIRE DEPT. r�NAL '
FIR1Al NEATING � HEA�TH DEPT. FIVA� �
FINA�ELECTRIC � i --•--„--------- DEV. FEES €'AID -- ;--
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FINAL PLUMBING ; � !
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CQMMENTS
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SEEPPiTlU SIZE -----...------..___....__----------- ---------------- ---- — ----
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Attachment A
Form for Non-Franchise Haulers for Construction and Demolition Requirements
,
Company and Project Info:
Name of licensed demotition contractor hauler or self hauling coinpany I"'���4-C� ���""�—
, Address of Company
'I cZ(2 D �� l-f2u��c� ��� City Y�-��e� �
Zip Code ���U� Phone Number �/`� ��7 �� �v
Address and Name of Project Site
L►�1-►ve l c��� . ,� /���, /� T3� �t � �� �' -
I �
Type of recycleable material or waste material to be transported for this project
��yD ��—�7-r�.�'"U— �-�j 7 '
Report Information:
Please submit this information prior to final building inspection.
' ' A report reflecting the following information:
• The estimated volume or weight of construction and demolition debris,listed for each
, ' material;
' • The estimated volume or weight of construction and demolition debris that can be .
diverted listed for each material;
� The estimated volume or weight of construction and demolition debris that will be
landfilled as waste; and
• Identification of the vendor or facility that will collect or receive the construction or
demolition debris.
AB 939 Fee Payment:
Pay AB939 fee of$6.00 per bin and$40 per roll off for all non-franchise hauler containers
Type of Container �✓�� ����� number of container
' Paid date(o�ce use only) (revenue code CD Waste)
Agreement and Signature: _
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold hannless the City for damage and
liability, including any financia]liability, fines and penalties, associated with using a non-City
franchised hauler and failing to satisfy diversion requirements. �
c���Pr perty Owner Signature Print Name Date '
- � F�.���..-= a � �
Self Hauler � ature Print Name Date
Last updated March 14,2008 �