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CITY OF DIAMOND BAR ` II
--�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 1•
w 21660 E.Copley Drive Suite 190 � �
� (909)860-3195 Fax(909)861-3117 PRESS
�����'�� BUILDING PERMTT APPLICATION �IRMLY
� JOBSITE � ` APPLICATION� (�,/� PERMIT � 3� P/C I
o ADDRESS �p tl�C1 h YCC'I/LO I XJ C S T DATE / �" NUMBER a
c� ISSUE rI TYPE OCC
APN LOT TRACT DATE � CONST. • GROUP
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Q ADDRESS . f J Ov A� i41 �'�E ' � PROPOSED USE
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFlMI UNDER FENALTV OF PERIURV THAT I AM EXEMPT FqOM THE CONTMCTORS LI- GBfflJB/CefPOff
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� COUNTI'N?IICHRC-0UIRESAPERMRTOCONSTflUCT,ALTERIMPROVE,DEMOLISH,ORREPAIRANYSTRUC• W Patio/Deck
TURE,PRqR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTMCTORS ll-
� CENSE UW(Ci1AP7ER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooVSpa
FESSpNS OODE)OR THAT HE OR SHE IS EXEMPT THEREFROM M1D 7HE BASIS FOR THE ALIEGED EXEMP-
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r ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(i500).):
� ❑I,ASOMMEROFTHEPROPERTY,ORMYEMPLOVEESWI7HWAGESASTHEIRSOLECOMPENSATION, � COfflfflOfClal �
WILL DO THE WORK,AND THE STRUCiURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70��,BU51� J
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
� PiqPEHTVNRiOBU1LD50RIMPROVESTHEHEON,ANDWHODOESSUCHM/OqKHIMSELFORHERSELFOq �
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� OFFERED�ORSALEIF.HOWEVERTMEBUILDINQORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE-
Z �TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SME DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
❑I,AS OWNENOf THE PROPERfY,AM EXClU51VELV CANTRACTINO WITH LICENSED CONTRACTORS
Q TO CONSTRUCT THE PROJECT(SEC.7oN,BUSINESS AND PROFESSIONS CODE:THE CONTMCTORS LI� VelUetlOfl ADJ.AREA
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� DATE ONMER F
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� LICENSED CONTRACTORS DECLARATION W
2 I HEREBV AFFIRII UNDER PENALTV OF PERIURY 7HAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � .
d Y(COMMENCWCi WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PROFESSIONS CADE,AND Z
X W UCENSE IS IN FULL FORCE AND EFFECT.
� LICENSE CLASS � LIC.NO. V S�� ( � �
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� WORKERS'COMPENSATION DECLARATIO -�
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� I HEREBY AFFIRM UNDER PENAL7Y OF PERIUFiV ONE OF THE FOLLOWING DECLARATIONS: �
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� 1 HAVE AHD WILL MAIN7AIN A CEi7fIFICA7E OF CONSENT TO SELF-INSUfiE fOR WORKERS' � 2
� COAIPENSATION,AS PROVIDED BY SECTION 370o OF 7HE UBOR CODE.FOH THE PERFORMANCE w
OF THE WOFK FOR WHICH 7HI5 PENMIT IS ISSUED. �
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w _I HAVE AND WILL AWMNN WORKERS'COMPENSA710N INSUMNCE,AS REOUIRED BY SEC710N � /�)
Q 3700 OF THE UBOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMI7IS � /r-r/
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBEH ARE: CONSTRUCTION � ••�
� CMRIER S'T�R T r F L9 IV C� pLAN REVIEW /��
�ZZ POLICV NUMBER ��LI C�1�— U C> ELECTRIC — �����f) �✓r
Q (TW6sEc.'rK1NrlE�r+orBEaoAFltrIDOFn#FEwiAfriSFOaa+EFiIN�DfiE000uAas(f�m)oRLEss). PLUMBING 1��A^:...�...0
Z I CERTIFV THAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS 7ERMIT IS ISSUED,I MECHANICAL
(,�J SHl�L NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE Ps�'�'ri,'
� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOU�DBECOME INSPECTIONFEE p'? � � ��-'��
S SUBJECT TO THE WORKEflS'COMPENSA710N PROVISIONS OF SECTION 3700 OF 7HE LABOR � V = ` � F S; /��
CODE,I SHALL FOHTHWITH COMPLV WITH THOSE PROVISIONS. �SSUANCE ���' ' -��T`�'� ��'�� ��L
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J WARNINO:FAILURE 70 SECURE WORKERS'COMPENSA710N CAVERAGE IS UNUWFUL,AND SHALL BE
� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUP700NEHUNDREDTHOUSAN� ENERGYPERMIT �4J��
DOLLARS(f100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 370E OF THE LABOR CODE,INTEREST,AND AT70RNE1"S FEES. � RETENTION FEE:
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a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIHM UNDER PENALTV OF PE0.IURV THAT THERE IS ACONSTRUCTION LENDING AGENCY
n- FOR THE PERFORMANCE OF THE WOHK FOR WHICH 7HIS PERMIT IS ISSUED(SEC.30Y7,CIV.C.). �
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� LENDER'S NAME
H LENDER'SADDRE55
� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORREC7. TOTAL FE ES / � ,
w I AGREE TO COMPLY WITH ALL CIlY AND CAUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
� CONSTRUC710N,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CAUNTV TO ENTEF UPON THE �
ZABOVE�MENTIONED PROPERTY FOR INSVECTION PURPOSES. COMMENTS
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m PERMITTEE NAME(PRIHT) ����
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� SIGNATURE OF PPAA117TEE . DAT
= RECPT.N0. PAID BY VALIDATION
~ WHITE—Depertment Copy,YELLOW�inence Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Copy
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SET BACK y ..; « .'- s_ . FLOOR JOIST . ; � '
FTGS/FORMS/STEEL � � � FHA REQMTS
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ELECTRIC GROUND
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GROUND PLUMBING UNDER FLOOR CCJ�E�7U17 .
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SLAB GRADE FIREPLACE FOU�iDATION
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TEMP POWER j FIREPLACE BOND BEAM
WATER SERVICE MIQ HT.BOND BEAM - �� —�
R�OF SHEATNING ! 8 Ff. B�NQ BEAM �
FRAMIfVGNENTILIATION FINAL BOND BEAM �
ROUF COVF_R PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ; ROUGH GRADING
ROUGH PLUMBING � � FINISH �RADING
SHCWERlTUB TEST POOL ELECTRIC
EXT. LATH/SIDING• • POOL FENCING �
WALL INSULATION P�OL FINAL
CEILlNG IPISULATION OFF SITE IMPS.
DRYWALL NAILING DEQICATIONS �
SEWER FINAL ENG.
SEi'TIC TANK LANDSCAPE/IRRIG.
5EE? PISlL.L. ON SITE IMPS.
C( �,�5 AI.-�c TEST FINAL ZONING , _
' .FlN�0.�CD(JST. ' FIRE DEPT. FIiVAL
FI�VAs HEATING HEAI.TN DEPT. FINAL
� ���i��„�ELECTRIC DEV. FEES PAID __
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