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�F�J CITY OF DIAMOND BAR �J
DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES
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(909)860-3195 Fau(909)861-3117 FIR LY
"":�;�'' gUILDING PERMIT APPLICATION
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u� NRE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W
� STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROV�SIONS OF TNE CONTRACTORS LI- � POOUSPB
� CENSE LAW(CHAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
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� I FIEHEBV AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER 7ROVISIONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBV AFFIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWINO DECIARATIONS:
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� _I HAVE AND WILL MAINTAIN A CEFTIFICATE OF CONSENT TO SELF-INSURE FOR Y�VRKERS' 2
Q COMPENSATION,AS PROVIDED BV SECTION a7o0 OF TME 1A80R CODE,FOF THE PEPFORMANCE w
OF THE WORK FOHYMICH THIS VEPMIT IS ISSUED. �
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w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BV SECTION
Q 3�o00FTMELA80RCODE,FORTHEPERFORMANCEOFTHEWOPo(FORWHIq1THIS7ERM1T15
0 ISSUED.MY WORNERS'C/OM7 NSATI N/IJNSURANC ARRIER �POLICV NUMBER ARE: CONSTRUCTION
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ZPOLICV NUMBER ���a 0 __- ._. ELECTRIC
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Z I CEATIFV TMAT W THE PEFFORMANCE OF THE WORK FOR WHICH THIS PERMIT tS ISSUED.I
(} SHALL NOT EMPLOVlWv PERSON IN/WY MANNER SOAS 70 BECOME SU&1EC7707HE INSPECTION FEE
� WORKERS'COMPENSATIONLAWSOFCALIFORNIqANDAGFEETHATIFISNOULDBEGOME .
r SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION J7ao OF THE LABOR ISSUANCE
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p DATE: APPLICANT: �,�,
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J WARNINO�FAIIURE TO SEWRE�'dOF�KERS'COMPENSATION COVERAQE IS UNUN�FUL.AND SHALLBE
�—y SU9IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNOREDTFIOUSAND ENERGYPERMIT
OOLLARS(floo.000).IN A�DITION TO THE COST OF COMPENSATqN,DAMAGES AS PROVIDED FOR IN ��
J SECTION 3]oB OF THE LA80R CODE.INTEREST,AND ATTOFNEV'S FEES. RETENTION FEE:
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� I HEREBV AFFlRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LEN�INO AGENCV
� FOR THE PEAFORMANCE OF THE WOR%FOR WHICH THIS PERMIT IS�SSUED(SEC.30H7,CIV.C.).
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� LENDER'S NAME
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wI CERTIFV TNAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �
� I AGREE TO COMPIV WITH ALL CITY AND CAUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CANSTRUCTION,AND HEREBV AUTNORRE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
ZABOVE-MEN7qNE0 PROPERTV FOR INSPECTqN PURPOSES. COMMENTS
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� WHITE—DepaAment Copy,YELLOW—Finance Copy.PINK—Assessor Copy,GOLDENROo---File Copy,GREEN—Applicant's Copy
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GROURJD PLUMBING `____ UNDER FLQOR CUf�IDUIT � ---r—
SLAB GRADE FIREPLAGE FOUNDATfON
TEMP POWER FIREPL CE B�ND BEAM
WATER SERVICE MID HT. BOND �EAM
R�OF SHEATHING 8 FT. BOND BEAM
FRAMINGNENTIUATION FtPlAL BOfVD BEAM
ROOF C�VER PR�-GRADING
ROUGH HEATING BENCHlNG
ROUGH ELEGTRlC ROUGH GRADING
ROUGH PLUIUIBING FINISH GRADING
SHOWER/1'UB TEST POOL ELEC7RiC
EXT. LATH/SIDING POOL FENCING
WAL�IIUSULATION POOL FINAL
CEILItUG INBULATIOIV OFF SITE IMPS.
DRYWALL NAILING �EDIGATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/lRRIG.
SEEP PIT/�.L. ON SITE IMPS. �
GAS AIR TEST FINAL.ZONING
FlNAL CONST. �lRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC ����AZ—�:y� DEV. �EES PAID
FINAL PLUMBING ENERGY
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