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CITY OF DIAMOND BAR �/ � 1
^---��-- DEPARTMENT OF COIvIIvILJNITY&DEVELOPMENT SERVICES ( ,j� �
21825 E.Copley Drive 1
(909)860-3195 Fax(909)861-3117 � PRESS
""-.9��' BUILDING PERMIT APPLICATION FIRMLY
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ADDRESS DATE `' � d NUMBER 1�/!� #
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p� �OWNER-BUILDER DECLARATION SFR/ADD/REM
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w 7URE.PRqR TO ITS ISSUANCE,�LSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIQNED w Petia/Deck�
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI�
� CENSE LAW(q1MTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOVSPB
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A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLLAAS(f500).): �
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Z WILL 00 THE WORYC,AND THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.701a,BUSI� J
N NESS AND PROFESSIONS CODE:THE CONTRACTOqS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
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CL THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS AqE NOT INTENDED OR m
Q OFFEREDFORS�LEIF,HOWEVERTIIEBUILDINOORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE�
Z TqN,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVINO T1MT HE OR SHE DID NOT BUILD OR
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W ❑I,ASOWNEROF7HEPROPERTV.AME%CLUSIVELYCANTMCTINOWfTHLICENSEDCONTRACTORS
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� ❑I AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON �
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1 HEREBY AFFIRM UNDER PENALTV OF PER1UfiV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� e(COMMENCINO WfTH SECTqN 7000)OF DIVISION J OF 7HE BUSINESS AND PROFESSIONS CODE,AND Z
��� MY LICENSE IS IN FULL FORCE AND EFFEC7. m
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N I HEREBV AFFIRM UNDER PENALTY OF PE0.IURV ONE OF THE FOLLOWING DECLARATIONS: � •� '�
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� _IHAVEMIDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORNqRKERS' a
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Q COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOH CODE.FOR THE PERFORMANCE U
OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED. � w
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w I HAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOq WHIp1 THIS PERMIT IS
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER A�ND�P+OUCV NUMBEF ARE: CONSTRUCTION
j CARRIER P � IAIS,� L�.C�. C}+. N �I�J_+�`/lt'J� PLAN REVIEW
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE MlORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C,'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE �� .-, ,
(/J WORI(ERS'COMPENSATIONLAWSOFCALIFORN10.NdDAOREETHATIFISHOULDBECOME INSPECTIONFEE � //_].\ TI yl ;�r '
S SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTIIELABOR �"' � � � -•+.
CODE.I SHALL FORTHWITH COMPLV WITH T1fOSE PROVISIONS. ISSUANCE I
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p DATE:S�J��Z APPLICANT: SMIP -
w ENERGY P/C I
J WARNINO:FAILURE TO SECURE M/ORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE
� SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED TFqUSAND ENERGY PERMIT ��.�
DOLLAAS(f100,o00).IN ADDITION TO THE COST OF CqMPEN5AT10N,DAMAOES AS PROVIDED FOR IN
J SECTION 3708 OF 7HE LABOR CODE.INTEREST,AND ATTORNEV'S FEES.
w RETENTION FEE: '� _ -- ..----�^-
O CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNOER PENALTY OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.J.
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� LENDER'S NAME
� LENDERSADORESS
w I CERTIFV THAT 1 HAVE READ 7HI5 APPLICATION AND STATE THAT THE ABOVE INFOPMATION IS CORRECT. TOTAL FE ES �O
� I AGREE TO COMPLV WfTH ALL GTV AND CWNTV ORDINANCES AND STATE UWS RELATINO TO BUILDING �
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OFTHIS CWNTV TO ENTER UPON THE
Z ABOVE�MEMIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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�, 51� RE OF PERMITTEE � DATE
� RECPT.NO. PAID BY • VALIDATION
WHITE—Depertment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—Fle Copy,GREEN—Applicant's Copy
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FTGS/�ORMSlSTEEL � FHA REC]MT5
ELECTRIC GROUND UNDER FLOOR QUCT
GROUND PLUMBING UNDER FLQOR CU�IDUIT �
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FI�EPLACE BOND BEAM
WATER SERVICE MiD HT: BOND EiEAM
RODF SHEATHING 8 FT'. BOND BEAM
FRAMIRIGNEIVTtLiATION FINAL BOND BEAM
ROOF COVER PRE-GRADING .
ROUGH HEATltVG BENCHING
ROUGH ELECTRIC ROUGH GRADING
R(�UGH PLUNIBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL Ih1SULATION POOL FINAL
CEILIPlG INSULATIUIV QFF SITE IMPS.
DRYWALL NAIUNG DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IRRIC,.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
F!lVAL COtVST. FIRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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