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CITY OF DIAMOND BAR C/ `�� ����� l �'��
-----��— DEPARTIv�NT OF COMMUNITY&D VELOPMENT SERVICES ��
21825 E.Copley mive
(909)860-3195 Fax(909)861-3117 PRESS
�4'%9�� BUILDING PERMIT APPLICATION FIRMLY
N JOBSITE �� �j !� 01_n � � APPLICATION +� � '����I NUMBER �I #/C r"�9
o ADDRESS "� ��Q DATE �
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APN LOT TRACT - DATE CONST. GROUP
p OWNER
p ADDRESS ZONING SETBACKS
z CITY ZIP TEL. FRONT qyy ❑
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z DESIGNER
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N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM E%EMPT FROM hIE CONTRACTORS LI- G0l8gB/COfpOR
W CENSEUWFORTHEFOLLOWINOREASON(SEC.7o3t.5BUSINESSANDPROFESSIONSCODE:ANVqTVOR (n
C.) COUNTVWHICHREOUIRESAPERMITTOCONS7AUC7,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANVSTAUG W pgtl0/D9Ck
w TURE,PRIOR TO ITS ISSUMICE,AL50 RE-0UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w
� STATEMENT h1AT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTORS LI-
� CENSE UW(CHAPTER B(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF hIE BUSINE55 AND PRO- � Pool/Spa
Q FESSIONSCODE)OR7HATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (�
V TION.ANV VqLAT10N OF SECTION 7031.6 BY ANV APPLICANT FOR A PERMIT SU61ECT5 THE APPLICANT TO Z Re-Roof
A CML PENALTY OF NOT MOFE h1AN FNE HUNDRED DOILARS(f500).):
� ❑I,ASONMEROFTNEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, � COfi1R10fC18I
Z WILL DO THE WORKµD THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70N,BU51- J �
� NE55 AND PROFESSIONS CODE:THE CANTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPEHTY WFiO BUILDS OR IMPROVES 7HERE-0N,AND NM110 DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGH HIS OR HER ONTJ EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
0 OFFEREDFORS�LE.IF,HOWEVER,THEBUILDINGORIMPqOVEMENTI550LDWITHINONEVEAROFCOMPLE�
Z TION,h1E OWNER�BUILDEH WILL HAVE THE BURDEN OF PROVINO THAT HE Ofl SHE DID NOT BUILD OR
� UAPROVE FOR THE PURPOSE OF SALE). '
W ❑I,AS ONRJER OF THE PROPERTV,AA1 EXCLUSNELY CONTRACTIN6 WfTH LICENSED CONTRACTORS
Q TO CONSTAUCT 7HE PROJECT(SEC.70N,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V8Il18IlOf1 ADJ.AREA
W CENSE LAW DOES NOTAPPIV TO AN OVMER OF A PROPERTV WHO BUILDS OR IMPROVES iHEREON,AND
� WFIOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECANTRAG QUANTITY DESCRIPTION
Y TOqS LICENSE LAW.). FEE
� ❑I AM EXEMPT UNDER SEC. B.8 V.C.f-0R THI$REASON �
2� U
� DATE OWNER F ,
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBV AFFIRM UNDER PENALTV OF PERIUFV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
p_, B(COMMENCWO WITH SECTION 70a0)OF DIVISION 3 OF THE BUSINESS AND FROFESSIONS CODE.AND Z
LL MY LICENSE IS IN FUIL FORC�jM1D EFFECT. m
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� LICENSE CLASS ,!A LIC.NO. L �
V DATE �� • �iI7 ` O CONT CTOR , a
W 1 �
� WORKERS'COMPENSA ION^DE AFtA 10 � ^�.e CS'
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N I HEREBV AFFIRM UNDER PENALTV OF PERJUPV ONE OF THE FOLLOWING DECLARATION � V
(/) Z
� _I MAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEM TO SELF-INSURE FOR WORKERS' a
2
Q COMPENSATION,AS PpOVIDED BY SECTION 3700 OF TME LABOR CO�E.FOR THE PERfORMANCE U
THE WOR)(FOR WHICH THIS PERMIT IS ISSUED. w
� �
Qw _I HAVE AND WILL MAIMAIN WORKEflS'COMPENSATION INSURANCE,AS REOUIRED BY SECTI(JN
370o OF THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK���QQQ R NR11CH THIS PERMIT IS .��
ISSUED.MV WORKE ' PENS ION INSU��IER AND P�LICY NUMBER AAE: CONSTRUCTION
j CARRIER � Y,%\ '—
PLAN REVIEW ��
0Z POLICV NUMBER__�_��� O � ELECTRIC
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� (fF115SEC1qNNE�NOTBE00MPLEfmOFh¢PEPIMISFORONEFiIR�DFEDDOLLARS(S1ao)ORLESS� PLUMBING
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Z I CEflTIFV TH�T IN THE PERf-0RMANCE OF THE WOR)(FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �
C} SH�LL NOT EMPLOV ANV 7ERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE
(/� WORNERS'COMPENSATION UWS OF CALIFORNIA,AND ACiREE TMAT IF 1 SHOULD BECOME INSPECTION FEE
SU&IECTTOTHEWORKERS'CAMPENSATION ROVISIO OFSECTqN 7000FTHE BOR � /
S CADE.I SHN.L f-0RTHWITH COMPLV WITH TH SE PRO�wr+s. ISSUANCE
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p DATE:�/• 2.� • O`APPLICANT. SMIP
W
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATqN COVERAGE IS UNUWFUL,AN SHALLBE ENERGY P/C
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�y SU&IECTAN EMPLOVER TO CRIMINAL PENALTIESPND CIVIL FINES UP TOONE HUNDFED T}KKISAND ENERGY PERMIT
DOLLARS(5700.000�.IN ADDITION TO7HE COST OF COMPENSATKKJ,DAMAOES AS PROVIDEO FOR IN
J SECTION 37oe OF THE UBOR COOE.INTEREST,AND ATTORNEI"S FEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AGENCY
FOR hIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
Z
W
� LENDER'S NAME
F— LENDER'SADDRESS
w I CERTIFV THAT I HAVE READ THIS APPUCATION AND STATE TFIAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES ' 1�S_
� I A(3qEE TO COMPLV WITH ALL CITV AND COUNTY ORDINANCES M!D STATE LAWS RELATIN6 TO BUILDINO /�
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO EMER UPON THE
Z ABOVE�MENTIONED PFOPERTY FOR INSPECTION PURPOSES.
� COMMENTS
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m PERMITTEE E(PRl �
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� SIONATU PE ITTEE � ATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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FTGS/F�RMS/STEEL � FHA RECZMTS.
ELECTRIC GROUND UNDER FLOOR DI�CT..'
GROUND PLUMBING UNDER FLOOF2�CUAIDUIT
SI..AB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLAC,E BOND BEAM
WATER SERVICE MIQ HT. BOND BEAM
ROOF SHEATHING 8 FT. BONQ BEAM
FRAMINGNENTILIATtON ' FINAI BaND BEAM
ROOF COVER PRE-GRADING
ROUCH HE,4TING BENCHING
ROUGH ELECTRIC R�UGH GRADING
ROUGH PLUPiIBING FINISH GRADING
SHOWERITUB TEST POOL ELECTRIG
EXT. IATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL �
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILIPVG DEDIGATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. FlRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FiNAL ELECTRIC DEV. FEES PAID
FIf�AL PLUMBIMG ENERGY
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COiVIiViENl'S ' �
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SEPTIC TAfVK SIZE
SEEP PIT/U SIZE
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