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�� CITY OF DIAMOND BAx
DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES
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(909)8643195 Fax(909)861-3117 PRESS
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�� _ CITY OF DIAMOND BAR � �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
��� 21660 E.Copley Drive Suite 190
(909)860-3195 Fau(909)861-3117 PRESS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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FIRMLY
DATECATI ' 77
ADDRESS ZAW �-�� "L�y�L D12 1
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NUMBER
APN LOT TRACT ISSUE TYPE OCC
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OWNER 7ti-n£14 OQel/C), CONST,GROUP
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DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
OWNER-BUILDER DECLARATION SFR/ADD/REM
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
Garage/Carport
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT.ALTER. IMPROVE. DEMOLISH. OR REPAIR ANY STRUC-
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W Patio/Deck
PRIOR TO ITS ISSUANCE
ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
LL.I
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CENSE LAW(CHAPTER 9(COMMENCING WITH SECTIO
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FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
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Z Re-Roof
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
DI.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
C1
Commercial
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI- J
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPRO
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S THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
CI D
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCTTHE PRO,ECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
Valuation ADJ
AREA
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH AC%NiTRACTOR(S)LICENSED PURSUANTTOTHECONTRAC-
QUANTITY DESCRIPTION FEE
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. B P.C. FOR THIS REASON J
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DATE
OWNER H
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LICENSED CONTRACTORS DECLARATION W
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT t AM LICENSED UNDER PROVISIONS OF CHAPTER 0
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 CF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FU
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LICENSE CLA LIC. N0.
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DATE II'
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i�CONTRACTOR L�wl'L
WORKERSCOMPENSATION DECLARATION Q
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECORATIONS: -
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HAVE AND WILL MAINTAIN A CERTIFIf.ATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. UJ
1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
�.-�
3700 OF
THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
,'•I.2 C'°C�
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PLAN REVIEW
CARRIER.lAA-0-4 PL-Sgt//-'t. .
POLICY NUMBEII_C_ino,'E-77776 2- ELECTRIC
(IRIS SECTION NEED NOT BE COMPLETED OF THE PErNAT IS FOR ONE HUNDRED DOLLARS($I00)OR LESS}
PLUMBING �{-•�
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
MECHANICAL
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR a a r q
CODE,I SHALL FOFITHWITH COMPLr WITH THOSE PROVISIONS. �
ISSUANCE
SMIP
DATE:APPLICANT + �;.•C.�
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WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
A
ENERGY P/C iBT ri�,_J
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SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
LJ li.i.,ry L�I C s
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
ENERGY PERMIT
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
o('°(•
CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE CF THE WORK FOR
WHICH
THIS PERMIT IS I
SSUED(SEC. 3097.CIV,C.).
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I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
TOTAL FEES i •'
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING �
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
COMMENTS
I
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PERMITTEE NAME(P 1
SIGNATURE OF ITTEE DATE
RECPT N0. PAID BY)"'VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
ULI)IIISU
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117
BUILDING PERMIT APPLICATION
AODDRIESS�.IF,�<7 d V�'C= �wq 'J'��� !�
APN I_OT TRACT
OWNER'���L3��/G,d
ADDRESS y�t�wX,lf: h+9.tf�"
CITY fs N iL�l(U ZIP'1(x� �TEL.
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CONTRACTOR 1••L�WCJtIJ-�
ADDRESS 2-!e'-/WLi'?J.V�F/Lit�..A�!
CITY UIi1.C:: ZIP I�UYo TEL.�'�1-Y76�L'
t,�,'Sr
ARCWENG/
DESIGNER SP'��-��N�1Z� iDlei9fi
ADDRESS(�17�M/IL'-YLi2.. �,T�T-
CITY L i;IM;'ZIP I!LTELq�r°!- 7L�/^ g
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMR70 CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE. PRK)R TO ITS ISSUIWCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW(CHAPTER 9(CXMAMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSK)NS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SL=CTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(1500).):
^ 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND"fl-1E STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.Told,BUSI-
NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOIVEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPFIOVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF THE PROPERTY AM EY.CLUSIVELV CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70.11, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OH IMPROVES THEREON,AND
WHO CONTRACTS FOR SU(:H PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE UW.).
^ I AM EXEMPT UNDER SEC. B. d P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTKNJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
AAY LICENSE IS IN FULL F
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WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNUr.R PENAI T'OF PERJURY ONE OF THE FOLLOWING DECURATIONS:
I NAVE AND WILL MAINTAIN A CERTIFICATE CF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,Ai PROVIDED BV SECTlON 37W OF THE LIBOR CODE, FOR THE PERFORMANCE
OF THE WORK FOE,WHICH THIS PERMIT IS ISSUED.
I HAVE AND W LL MARdTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTlON
3700 OF THE LA@OR CODE,FOR THE PERFORMANCE OF THE WORK FUR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENS TKXJ INSURANCE CARRIER AND POLICY NUMBER ARE:
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(TI-pS SECTlON NEED M77 BE NI.IPLEIEOOF7NE FERMff IS FOR ONE HUNDRED DOLLARS(1100)OR LESS
I CERTIFY THAT IN'fHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON fN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT iF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LIBOR
(:ODE,I SHALL FOFITHWITH COMPLY WITH THOSE PROVISKNS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLURS(1100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTON 3708 OF THE U&�R CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OFf
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LENDERS NAME
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LENDERS ADDRESS ���1/-'C����V� IJ�A�U,v'-IW
I CERTIFY THAT I HAVE REP.D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
1 AGREE TO COMPLY WITH �LLL CITY ANO COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTK)NED PROPERTY FOR INSPECTION PURPOSES.
�-; �cU,�
PERMITTEE NAM (PRINT)
SIGNATURE PE ITTEE'. DATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
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PRESS
FIRMLY
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U1,1�IOJI1
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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DESIGNER
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CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRESA PERMR TO CONSTRUCT ALTER,IMPROVE, DEMOLISH,OR REPAIRANV STRUC-
TURE,PRIOR TO ITS ISSUIWCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR E.HE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE IAW(CHAPTER 9((XM/MENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSgNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VKxATKKV OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND-niE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS IX)OE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PFK)PERTY WHO BUILDS OR IMPROVES THEREON,AND WHO GOES SUCH WORK HIMSELF OR HERSELF OR
THRW(iH HIS OR HER OWV EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WRHIN ONE YEAR OF COMPLE-
TKXI,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPO:iE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM E%CLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT AP{'LV TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUC'.H PRO.IECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.1.
^ I AM EXEMPT UNDER SEC.8. E P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY Of PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTKKJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,ANU
MY LICENSE IS IN FULL FOfiCE AND EFFECT
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DATE I1-3(-T"Z-UuJ CONTRACTOR L' LIIG'��Z
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECORATIONS:
1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PNOViDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOE.WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'WMPENSATION INSURANCE,AS REQUIRED BY SECTlON
3700 OF THE LA,BOIT CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORY,'�_RS'
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POLICY NUMBER_V L> � � �(,7
(niC SEL"1)ON NEE'il NOT BE COA1P_ETED OFTHE PERMT IS FOp ONE HUNDRED DOI-CARS(5100)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
St1ALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO 9ECOME SUBJECT TO THE
WORKERS'CCkAPEN5AT10N LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD B'cCOME
SU&IECi TO THE NIORKERS'COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR
CODE.I SHALL FOFIT}IWITM COMPLY WITH THOSE PROVISK)NS.
DATE:APPLICANT
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,ANU SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATON, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LA&�R CODE,INTEREST AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMAN
C
OF T
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WO
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FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
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I CERTIFY THAT I HAVE READ THIS APPLICATK)N AND STATE THAT THE ABOVE INFORMATpN IS CORRECT.
I AGREE TO COMPLY WITH �4LL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
C(NVSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
JCW�- ���
PERMITTEE NAME RINT)
SIGNATURE RMITTEE: GATE
WHITE-Department Copy,YELLOW�inance Copy,PIN
PRESS
FIRMLY
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUII,ZSING PERMIT APPLICATION
JOBSITE�//�_
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ARCH/ENG/
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
1 HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLDWING REASON (SEC. 7031.5 BUSINESSAND PROFESSKNS CODE: ANY CITY OR
COUNTY WHICH REWIRESA PERMITTO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRgR TO ITS ISSUIWCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI�
CENSE LAW(CHAPTER 0 ((%)AIMENCINO WITH SECTlON 7W0)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED E%EMP-
TION.ANV VKXATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(SSWJ.):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND'D1E STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70u,BUSK
NESS AND PROFESSIONS Ix1DE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOIVEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER4)UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM E%CLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7014, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
NATO CONTRACTS FOR SUCH PROJECTS WITH ACON7RACTOR(Sj LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. d P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTKKJ 70W)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COb'e,AND
MY LICENSE IS IN FULL FO� D EFFECT����//
LICENSE CUSS
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DATE F CONTRACTOR
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OR EENSATION DECLARATION i � �
1 HERE
B FFIRM UNOER P
ENALN OF PERJURY ONE OF THE FOLLOWING DECLARATK)
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTlON 37W OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOF WHICH THIS PERMIT IS ISSUED.
-I HAVE AND WILL MAINTAIN WORKER
ENSATION INSURANCE.AS REOUiRED BY SECTION
37W OF THE LABOR CODE,FOR THE PE RM E OF THE WORK FOR WHICH THIS PERMI715
J
ISSUED. MY WO$I! ENSA NS NCE CARR
ANO POLIC UMBER ARE'
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CARRIER 6/�M
POLICY NUMBER�
(1/CB SECTlON NEH7 NOT BE CON1PLEtED OFTFE PEFMTIS FOR CINE HUNOFiED OOI.IAAS(5100)LEAS).
I CERTIFY T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NO PLOY ANV PERSON IN ANV MANNER 50 AS TO BECOME OBJECT TO THE
WORKE'COMPE TKNI LAWS OF CALIFORNIA,AGREE I SHOULD BECOME
SUBJ TO THE RKERS'COMPENSATION P K)NS EC N 3700 OF THE LABOR
I SHALL RTHWITH COMPLY WITH TH V
DAT� � ��APPLICANT
WARNING: FAILURE TO S :ORE WORKERS'COMPENSATION COVERAGE IS UNLAWFVL,AND SHALL BE
SUBJECT AN EMPLOYE TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(fl W,OW),IN ADIJITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER F'ENALN OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE REI,D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT.
I AGREE TO COMPLY WITH ALL C AND C UNN ORDINANCES AND STATE LAWS RELATING TO BUI! DING
CONSTRUCTION,AND HEREBY HORI REPRESENTATIVES OFTHIS COUNTY 70 ENTER UPON TH
ABOVE-MENT
PROPER PoR I ECTlON PURP
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WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
PRESS
FIRMLY
31�1a
7�
U1,1)IIISII
1,1R I
Ire:,r
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT'APPLICATION I,
ADDRIESS Z.� 16��Gq�IT b3Ah CG1J�ti:(�'2�a?
APN LOT TRACT
OWNER'TEA dM�"U� I�Q.Cw�
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ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
1 HEREBY AFFIRM UNIDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOW LNG REASON (SEC. 7037.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
CWNTY WHICH REQUIRES A PERMR 70 CONSTRUCT,ALTER IMPROVE. DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR :iHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER G (IXJAiMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED EXEMP-
TION.ANVVIOLATION OFSECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACME PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).):
^ I,AS OWNER OF TH E PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND'THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7014,BU51�
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE VFAR OF COMPLE-
TK7N,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OVMER OF THE PROPERTY AM E%CLUSIVELY CONTRACTING WITH I.ICF.NSEU CONTRACTORS
TO CONSTRUCTTHE.. PRC1.tECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE: 'HE CONTRACTORS LI-
CENSE LAW WES NOT APPLY TO AN OWNER OF A PROPERN Wh10 BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SU<:H PROJECTS WITH A CONTRACTOR(S)L'CENSED FIJRSIiANT TO THE CONTRAG
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REP�+ON
DATE OWNER -
LICENSED CONTRACTGRS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURV THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTKNJ 7000)OF DIVISION 3 OF iH�c BUSINESS AND PROFESSIONS CGL�E,AND
MY LICENSE IS IN FULL FOH
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ANG EFFECT.
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DATE�?'� �'�� CONTRACTOR °'3�'ZWl
W(TRKERS'GOMPENSfiTION DECL;�RATIGN �>'�'
I HEREBY AFFIRM UNDER FEMALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
I HAVE AND WILL MAINTPJN A CEP.T!FICATE OF cANSENT TC SELF-INSURE FOR WORKERS'
COMPENSATK'.N.AS PROVIDED B':'SECTION 3]00 OF THE LABOR CODE, FOR THE PERFORMANCE.
OF THE WORK FOR WHICH THIS PEHIAIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, r�5 REUL�IREG 6Y SECTION
37000E T}IE UFIUH CODE. FOR THE PERFORMANCE OF THE WOFIK FOR WHICH THLS PERMIT IS
:^uSUED. MV WOI7KER5'COMPENSATION INSURANCE CA
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POL'CY NUMBEfi_�Q��-���V,�__i_{�f�,
(D9S SECTlDty NEED NOT RE CCMPI-ETED OF T}E F'f�F3/!T 6 rINJ ONE HUNDRED DOLLARS;Sio010R LESSj.
I CERTIFY-MAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLU V ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJE"T TO THE
WORKERS'COMPENSATION LAWS OF CALI'rORNIA,AND AGREE THAT IF I SHOULG BECOME:
SUBJECT TU THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
C00 E, 1 SHALL FUH"HWITH COMPLY WITH THOSE PROVISIONS.
DATE:_,_.APPLICANT:___
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVEHAGE;S UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN AUDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.j.
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE REPD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH �4LL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTKNIED PROPERTY FOR INSPECTK)N PURPOSES.
PERMITTE AM I
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NATURE OF PERMITTE : DATE
WHITE-Department Copy,YELLOW--Finance Copy,PIN
PRESS
FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
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APN LOT TRACT
OWNER tea-I LL COW C,
ADDRESS: 0%CAStPV+
CITY"*jcinv&ZIP AL-64 TEL.
APPLICANT TEL.
CONTRACTOR_So i.ji tZ fr LPL CL' L� 1J �-
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
OUNTY WHICH REOUIRES A PERMRTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
DI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF,HOWEVER.THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
D I,AS OWNER OFTHI_PROPERTY,AM EXCLUSIVELY CON r RACTING WITH UCENSED CONTRACTORS
TO CONSTRUCTTHE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
D I AM EXEMPT UNDER SEC. B.A P.C. FOR THIS REASON
DATE
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOFCE AND EFFECT.
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LICENSE CLASS LIC. N0._
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER P=NALTY OF PERJURY ONE. OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK I OR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOI.IIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS"COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER I>u17
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POLICY NUMBER(
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(THIS SECTION NEF.)NOT BE rx:AAFLFOEDOF THE PERM)IS FCIS:I IE I-tNDRE J DOLLARS(SI 00)OR LESS).
I CERTIFY THAI IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EHPLO"ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD B OME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF TION 00 TI LAB
CODE.I SHALL FORTHWITH COMPLY WITH THO ROVI
@w...7V_L1G
DAT2!T"�^1�'r '�APPLICANT:
WARNING: FAILURE TO SECJRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100.000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PI'NALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE of THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097, DIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
p
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PERMITTE E(P INT
SI&WATURF OF PE ITTEE DATE
APPLICATIO G PERMIT
J P/C
1
DATE NUMBER- 1 #
ISSUE TYPE OCC
DATE CONST,GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0.
- N0.
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DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM
Garage/Carport
w Patio/Deck
U- POOI/Spa
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Re-Roof
Z
Commercial
5
M
Valuation ADJ.AREA
QUANTITY
DESCRIPTION FEE
a3 IL, F4_ -7 L
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PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
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ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 75 (/�J
COMMENTS
RECPT. N0. PAID BY VALIDATION
1
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
U1,1NII�U
:sM
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUII.DING PERMITAPPLICATION ��
PRESS
FIRMLY
APPLICATIO
--Z i� PERMIT� ��� p/C
DATE NUMBER� #
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT Ryy^
REAR^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE
�r
N0. DWEL. N0. � 7
UNITS STORtf{r55 BEDROOMS
DESCRIPTION S0. FT FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
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Z Re-Root
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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PLAN REVIEW_
ELECTRIC - �� GZ6
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE -� �
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ENERGY P/C
ENERGY PERMIT��� ' "
RETENTION FEE: -, �__
PRE-ALT FEE: �i t�-
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TOTAL FEES�����,Cdil
COMMENTS__
RECPT N0. PAID 8Y
�"'J VALIDATION i
WHITE-Department Copy,YELLOW-Finance Copy. PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy