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, ` _��_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES • �
i ,� , - � 21810 Copley Drive,Diamond Bar,CA 91765 � PRESS
� (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-702
`�'%����W BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE 2��„+01 /'�„�b'� �t . q���5 APPLICATION PERMIT Zi ��C
o ADDRESS ��' DATE �d���/�� NUMBER' /��' #
ISSUE r TYPE OCC
� APN LOT TRACT DA7E �TI � CONST. �'��� GROUP �F2
� OWNER �aSmN P�SIa
� O G 7 b�� CT ZONING SETBACKS
ADDRESS �`{4 I FRONT RW ❑
OCITY'�IZw.o••►d C3a✓� ZIP°1t�Co'j TEL.�ty 'I�11 (o171Q REAFi ❑
o APPLICANT C4-�+' F-`R-�'A f ow TEL.1�'�7'1l �{04o SIDE/SIDE STREET RW ❑
� CON7RACTOA ��CoKHdti� o �at+- SIDE �
� ADDRESS 1�-tao No a acoc S'r (� P O OSED USE�D�✓GT�� �Q.7�f R t�lS e F'iCS T�G f lfjY1 b
� CITY �w a h e��^-� 21P g 1 � TEL'1 14�77�Ib� O S.�sT�FIf 'y+Fie e►+-f 3�' f�' �e /t
w ARCH/ENG/ ��'j�. (q'O O=wa� ��46/e 2/�S i� GT t.ur T� l� .� �/SF�
z DESIGNER N�� - NO.DWEL NO. NO.
a ADDRESS UNITS �N� STORIES � � �' BEDROOMS
� CITY . ZIP TEL.
. �
DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIQN
� OWNER-BUIIDER DECLARATION � SFR/ADD/REM
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� 1 HEREBY AFFlRM UNDER VENAL7Y OF FERNAV THAT I A/d E%EMPT FROA1 THE CONTRAC70R5 U� Gef8g0/CBfPOfS
W CFN^�EUWFORTHEFOLLOWP1aFlEAANI5EC.7031.6BU51NE55ANDPROFE5S10N3CO0EMfYCRYOR (n .
� G� CpJN7YVMiCHREOUIRESAPERMRTOCONSTAUCT.hl1'E0.�9AOVE.�EAtOlJS1i3ORFlEP�IRANVSTRUC �JJ P8[IO/DBCI( . .
�� NAE P{iIOR TO�RS�SSUANC�ALSO NEOUIRES THE APPLICANT WN SUCH FERM�T TO FlLE A SIONED w
STATEYF.Nf THAT HE OR SHE IS LICENSED PURSUANT TO THE PROYISIONS OF THE CONTRACTOR9 L4
� CENSE UW(CHAPTEA Y(�MENCW(3 WITH SECTIOI`17oDo)OF DMSION 7 OF iHE BUSINE55 AND PRd � P�SpB
f'ESSqN3 000�OR iHA7 HE OR SHE�19 E7(EMPT THEREFROM AND THE BASIS FOR 7HE ALLECiEO EJ(EMP•
E (�
TpM,AM/.VKKATIONOFSECTlON7oJ168YANVMOLICMI�FORAPERMITSUaIECTSTFIEAPPl�CM1TT0 Z� RaRoot
� ACML PENALT'�F NO7 MORE 1H/W F'ME HUNDRED DOLLMS({SaD}r' ��
� ❑I,ASOWNEROFTHEPROPERT'.oRMYEMPLAVEESWfT11M'A(3ESA9THEIRSOIECOMPENSATION, � 0 Commercial�
Z ylR1 pp 7NE WOfiK AND THE 9nM1CNRE IS NOT IN7FN�ED Ofi OFFERED iOR SALE(SEC.�7ou,8115F J
� NESS ANO PROFESSIONS CODE:TNE CANTRACTORS UC[NSE�LAW DOES NOT APVLV TO AN.OWNER OF ?
pqppERTYVh�OBU6.D30R1A1PROVE97HEREON.ANDNM1/O00ES5UCHWOAKHIMSELFORHERSELFOR m . . .
� 1HROUGHWSORHERONME�47LOYEES.PROVIDEDTHATSUCNWPROVEMENTSARENOTWTENDEDOR
WO OGFERmfORSALEIF,HOWEVERTME6tADINOORIMPROVEMEM�S.,OLDN�TMNONEYEIROFCO1JPlE .
Z �qN,TME OWNER�BUILDER WILL HAVE TNE OUROEN OG.P0.0VRN3 7FIA7-NE OR SHE DIO NOT Bl11lD OR
= IMPHOVE FOR THE RIRPOSE OF SALE} . . . .
❑I.A90WNEROF.THE PRDPERIV.�AA1 E%0.W�NELV CONTIUCTW(3 WfTN ItCENSE�CONTRACTORS i
Q Tp CpNgTqUCT T}iE PROJECT(SEC.7oN,BUSINESS AND PROF'SS10M5 CODE:THE CONTRACTORS LJ- V01U8tIOft� � ADJ.AREA
W CHiSE UW DOES NOTAP7LY.TOAN OWNER OFA VNOPER7V WMO BURD9 0R IMPROVES THEAEON,AND .
Z WYqCOHTRACTSFOH3UCHPROJEC'f9WIT1ACONTRACTOR(S)LICENSEDPURSUANTTOTHEODNTRAC- QUAMITV DESCRIPTION FEE �
� TORS UCENSE UW.). . �
0 ❑I AN IXENPT W�DER 6EC. 8.8 P.C.FOA 71U5 RE!�N U
� Q
� DATE . . . . OWNER V .
Z W
� UCENS£D CONTFACTORS DECLAflAT10N J �
� W
1 HEREBY AFFlN.1 UNDER PENPLN OF PERNRV THAT I AM LICENSED UNDER DqOVIS10NS OF CHAPTER �
� p ICOMMENCWO N7TH 5ECT10N.7o00)OP DIVISION J OF THE BUSINESS AND PROFESS�ONS CODE.AND Z. . . . . .
IIY LICENSE I3 R1 FU-L FORCE AND EFFECT.
� 7 l � m
� UCENSE CLASS ���.No.. l�4 3� o� � .
von� L/� �/ 1'� corrrFucmA t1 GCo�-►��c c a
w 120�.�t�
� WORKERS'COMPENSATION DECLARATION � � � �
� U
� 1 HEA�Y AFFIAII UNDER PENAITY OF PERJUflY ONE OG THE FOLLOW W O DECIARAT10N5: Z
O _�HAyEAMDWtLLMA1NTAIHACEFiIIFlGTEOFCANSEMTOSEIF-WSUREFORWORI(ERS' �
Q COMPDISATION.AS PROVIDED BY SECTpN 3700OF 7HE UBOR CODE,FOR THE PERFORMMICE �U�
OF iYIE WORK FOR WHICH 7HIS PERAIIT 19,ISSUED. �
� �1 HAVE AND WILL EWNTAIN.WOflKEfi,4'COMPENSATION INSURANCE:�S REW�RED BY SECTION . . /�/ ,/
Q 37a0 OF THE U�BOR CUDE.FOR THE PERF9RMANCE OF TME WORI(FOR WFOGI TNIS GEf1MI71S �• OC�
� ISSUE2 M`/ FAS'CWIPENSATION INS CAfiRIER AND POLICY NUMBER ARE �CONSTRUCTION� l��
� CAARIER �-e�t t Ca w� �s-�..21�l� Puw,a�viEw
0 voucv NUMeEA W C Q��d��.�I O I ELECTRIC
� (nussEcnor+�r+aieEooMttEtIDaFn+ePEarxtswaa+E�Oaluisls+ooloa�ssl PLUMBING
w MECHANICAL
Z I CEfiTIFV THA7 M THE PERFOMIANCE OF THE.WOR1(FOR WHIp1 THIS PERAUT IS�SSUED,I
Lj SHALLNOTEMPLOYAM'7ERSONWANYMANNERSOASTOBEWME�SUBJECTTOTTIE INSPECTIONFEE
� NOPo(ERS'COAIGENSATION LA`NS OG CAIIFORNU,AND A(iREE 7NAT IF I SHOULD BECAME . .. . .
SU&IECT TO TME WORKERS'COMPENSATqN PROV�SIONS OF SECTION 37ao OF iHE LABOR ISSUANCE
COOE.I SW��L/L fOHfM417H CO�PIV Wlhl/7�bS E PFDNSIONS. .` S�
p DATE: •O I a I I�APPLICANT:�. (�C+� �s�� .SMIP .
� WARNINO:FAaLRE TO SEWRE wORKERS'COMPENSATION COVE�UGE IS UNUWFUL.AND SHALL 8E EtJERGY P/C _ .
�y SUgJECT�N EMYlO�'ER TO CAININAL PENAL11E5 AND CML FPIES UP TO ONE HUNORED TiqUSAND ENERGY PEHMIT . �
DOLUAS(f1aD,DDo),Rl ADD�7KN�TOTHE C0.ST OF COMPENSATION,DAMAOES AS PROVIDFA FOR IN O O
JpC 6ECTION 370!OF h7E LABOR CO�E.W�ERE3T,/NID ATTORNEYS FEEs. - RETENTION FEE: � :
�� . CONSTRUCTION�IENDINGAGENCY � -PRE<-UALTFE •
�1 . 0
� I HEREBV AFFlRM UNDER PENALTY OF PERlURY T/U7 THERE IS ACONSTRUCTION LENDWO AOENCV J
�z' �FOR THE PERf4FU1N7CE OF.7HE WOPo(FOR WHICH TH�S PERMI715155UFD(SEC.�3UD'7,qV.C.} .
W ,
�, LENDEfTS NAME .. . . .
� IENOER'SAODF7ES4 . - 2
� �CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE i/iAT THE ABOVE INFOHMATqN�9 LORRECT. TOTAL FEES � J
W I A(iREE TO ODMPLY WIiH ALL CRV AND COUNTY ORDWANCES AND STATE UN5 RELATWO TO BUIlDINO . '
� CONSTRUCTION,AND HERF�V AUTHORI2E REPRESENTATNES OF Ti15 CWNTV TO EMER UPON iHE
Z� ABOVE-MENiYJNED PROPERiY FOfi INSPECTION 7URPOSES. .
COMMENTS "
� ��S � �CO�a
�
m ITTE E(PRINn � . . .
¢ s.�� G/� �
� 510 NRE OF PERMITfEE D E �
RECFT.NO. PAID BY VALIOATION
� WHITE—Department Copy.YELLOW—Finarwe Copy.P�NK—Assessor Copy�GOLDENRO�FlIe Copy:GREEN—Appl�ant's'Copy
CITY QF DIAMOND �AR '
INSPECTION REC�JFtD ` �
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�- . . �. _. �.� .:;�s�� :t�-. ,
SET BACK I FLOOR JOIST
FTGS/FORMS/STEEL F AH REQMTS
�--- —
ELECTRIC GROUND i UNDER FLOOR DUCT
GROU�D PLUMBING �UNDER fLOOR CONDUIT
SLAB GRADE �FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT.BOND BEAM
ROOF SHEATHING ,4 ( �8 FT.BOND BEAM
FRAMING/VENTILATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT.LATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL
CEILING WSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
SEWER FINAI ENG.
SEPTIC TANK LANDSCAPE/I RRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIRTEST �FINAL ZONING
RNAL CONST. �' �,,, FIRE DEPT.FINAL
fINAL HEATING HEALTH DEPT.FIIVAI
fINAL ELECTRIC DEV.FEES PAID
fINAL PLUMBING ENERGY
FINAL PLANING
FINAL ENGINEERING � o �a "
,
� _
COMMENTS
t^Do_� n t`e.e��.n� �.��ro►o
�«���-�t a��z—�
SEPTICTANK SIZE
SEEP PIT/U SIZE
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� ,, Attachment A
Form for Non-Franchise Ha�lers for Construction and Demolition Debris
Company and Project Info:
�
�tion contractor hauler or self haulin com an Co t2V� ►'�C�L ��1�'`��
Name of licensed demoli S P Y �
' 1 1 -� A
Address of Company � ��S� No l���c E �z � �d� City yt7�-�a �e c v-`
Zip Code ���� Phone Number �1� 7�7 ����
Address and Name of Project Site
, �4�c c�I �a�i 1� C-�. � l� C.e S. ��,
Type of recycleable material or waste material to be transported for this project
� C�-►��.s��te Ti I�
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
v Identification of the vendor or facility that will collect or receive the construction or
demolition debris. .
AB 939 Fee Payment:
Pay AB939 fee of$12.00 per bin and $50 per roll off for all non- franchise hauler containers
Type of Container number of container
Paid date(office u.se only) (revenue code CD Waste)
Agreement and Signature:
The property owner agrees to submit documentation to demons�-ate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold harn�less the City for damage and
liability,including any financial liability, fines and penalties, associated with using a non-City
franchised hauler and failing to satisfy diversion requirements.
Property Owner Signature Print Name Date
(�-%�� � L���5 Z �e,2.Co�4 v v-� l 8 ��S l�'
-- Self Hauler Signa Print Name Date
Last updated June 26,2008
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