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�� CITY OF DIAMOND BAR � � � ���
� DEPARTME'�'T OF COMMUNT('Y&bEVELOPMENT SERVICES /
I. � 21825 E.Copley Drive
�� (909)860-3195 Fax(909)861-3117 pRE$$
� �+�^ BUILDING PERMIT APPLICATION FIRMLY
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c� STATEMENT THAT HE OR SNE:S LICENSEO PUqSUANT TO THE PPOVISIONS OF THF CON7RACTORS 11-
� CENSE LAW(CHAPTER 9(COMMENCING Wi7H SECTION 7000)OF DIVISION 3(�F THE BUSME55 AN�PRO- LL POOUSP3
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� NESS AND PROFESSIONS CODF:THE CONTRACTORS LICENSE LAW DOc'S NO�APPLY TO AN OWNER OF
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� I NEREBYAFFIHM UNOER PENALTY OF PERJURY THAT I AM UCENSED UNDER PROViSIONS OF CHAPTER �,
d 9(COMMENCING WiTH SECTION 7000)OF DiVISpN 30F THE BUSMESS AND PP.OFESSiJNS CODE,AN0 Z
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Q OF THE WORK i"OR WMICH THIS PERMIT IS ISSUED. �
w �i HAVE AND WILL 1AAINT4IN WORKEPS'COMPENSATION INSUqANCE,AS REOUIRE�BV S[CTION
Q3�0o OF THE�PHOR CO'JE,FOP THE PERFORMANCE Of THE WOFK FOfl WHICHTHIS PERMIT IS
I55'JED.MV WORKERS'COMPENSATION INSVFANCE RRIER AN�POLICY NUM6ER ARE' CONSTRUGTION
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Z I CERTIFv THAT IN THE PERFORMANCE OF THE WORK FOR WHIGM THIS PEflM1T IS ISSUED,I MECHANICAL
C7 SHALL No�EMPLOY ANV PEFi50N IN ANV MANNER 50 AS TO BECOME SIIBJEfTTO THE - '
Uj WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULO BECOME INS?ECTION FEE
F SUBJECTTO THE WORNEFS'COMPENSATION PROVISIONS OF SECTION 370o OFTHE UBaR
CODE.I SHALL FORTHWITN COMPLY WITH THOSE PROVISIONS. / ISSUANCE _ L
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J SFCTInN i)Oq OF TNE LABOR CODE.INTEREST,ANp ATTORNEV'S FEES. ��
OC RETENTION FEE:
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� IHEREBVAFFIRMUNDERPE�AI.TVOFPERJURYTHATTHEREISACONSTF,UC'ION�ENDINGAGENCY
� FOR THE PERFORMANGE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.). --
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� LENDEN'S NAME _ _ -
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w ICERTIFYTHATIMAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT TOTAL FEES /�`/ �•�, J
� 1 AGR�E TO COMPLY WITH ALL CITY ANO COUN7V OR�IkANCES AN�STATE UWS FELATING TO 9UILDING / v �/
� CONS7RUCTION,ANDNEREBYAUTHORiZEREPREScNTATIVE50FTHISCOUNTVTOcNTER1IPONTHE /�
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CITY OF DIAMOND BAR
DEPARTME'VT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
WHITE-Department Copy,YELL-OW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
PRESS
FIRMLY
APPLICATION PERMIT P/C
DATE NUMBER #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR ^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE I r" .L1 L-� �e I � •�
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREA/VALUATION
SFRIADD/REM
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W Patio/Deck
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QUANTITY DESCRIPTION FEE
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ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE �,
SMIP
ENERGY P/C
ENERGY PERMIT_
RETENTION FEE: ��
PRE-ALT FEE:
TOTAL FEES 325,��
COMMENTS
RECPT. N0. - PAID BY VALIDATION