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�� CITY OF DIAMOND BAR � i
�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
ai�o E.c�iey nr;�e s�c�i90 PRESS
. �, (909)860-3195 Faa(909)861-3117
�? ����»�� BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE �y/� � APPLICATION . Jy� PERMIT �� P/C��1�-��
Q ADDRESS L�v �� � DATE �I NUMBER # !
� � ISSUE TYPE OCC
� �APN LOT TRACT DATE i � CONST. GROUP
°C OWNER Lv�-?�. A�.S
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ADDRESS G:4M�.iL - ZONING SETBACKS
� CITY ZIP TEL. FRONT RW ❑
APPLICANT TEL. REAR ❑
SIDFJSIDE STREET RW ❑
� CONTRACTOR SIDE O
Q ADDRESS PROPOSED USE 3 ��� ��b"�-� � �7t OaJ�
CITY ZIP TEL.
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� DESIGNER
� ADDRESS NO.DWEL. NO. NO.
UNITS STORIES BEDROOMS
� CITY ZIP TEL.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFlRM UNDER PENALTV OF PEiL1URY 7HAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f99B/CBfpOfl
W CENSEUWFORTHEFOLIOWINGREASON(SEC.7a71.5BUSINESSANDPROFESSIONSCODE:ANYCITVOR (n
� COUNTVWHICHREWIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORHEPAIRANVSTAUC- W P8SI0/DBCk
NRE,PRIOR TO ITS ISSUANCE,�L50 RE�UIfiES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNE� W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTMCTORS LI�
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 70D0)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSPB
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREfqOM AND THE BASIS FOR THE ALLEGED EXEMP•
TION.ANVVpUTIONOFSECT10N7031.50YANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTY OF NOT MORE 7HAN FIVE HUNDRED DOLURS(i5o0).�:
� OI.ASOWNEROF7HEPROPERTV,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial -
YALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OF OFFERED FOR SALE(SEC.70N,BUSI- J
HESS AND PROFESSIONS CODE:THE CANTRAC70R5 LICENSE UW DOES NOT APPLV 70 AN OWNEH OF
� PROPERTVW/10BURDSORIMPROVESTHEHEON.ANDWHOOOESSUCHWORKHIMSELFORHERSELFOR �
Q TNROUGH HIS OR HER OWN EMPLOVEES,PROVIDED 1HAT SUCN IMPROVEMEN7S ARE NO7INTENDED OH m
� OFFEREDFORSALEIF,HOWEVERTMEBUIIDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
, Z �TION,THE OWNER-BUI�DER WILL HAVE THE BURDEN OF PROVIN�THAT HE'OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE). �
❑1,AS OWNER OF THE PROPEHTY,AM EXCLUSIVELY CONTMCTING WRH LICENSED CONTRACTORS
� TO CONSTRUCT THE PHOJECT(SEC.7ou,BUSINESS AND PROFESSIONS CADE:7HE CONTRACTOHS ll� V81U0110l1 � I ADJ.AREA
W CENSEUWDOESNOTMPLYTOANOWNEROFAPROPERT'HMOBUtLDSORIMPROVES7HEREON.AND
� W/1000HTMCTSFORSUCHPR0.IECTSWITHACONTMCTOFi(S)IICENSEDPURSUMITTOTHECONTMG QUANTITY DESCRIPTION FEE �
TORS LICENSE LAW.).
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O ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON U �6 S
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F LICENSED NTRACTORS DECLARATION w
� I HEREBYAFFIRM UNDER PENALTY OF PERIURY 7HAT 1 AM LICENSED UNDER PROYISIONS OF CHAPTER �
� Y(COMMENCINO WITH SECTION 7000)OF OIVISION 3 OF 7HE BUSINESS AND PROFESSIONS CADE.AND Z
�� MY LICENSE IS IN NLL FOHCE MID EFFECT. m
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� LICENSE CUSS LIC.NO. J
, V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION �
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� I HEREBV AFFIRM UNDER PEN�LTY OF PE0.1UM ONE OFTHE FOLIOWING DECURA710N5: �
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� IHAVEANDWILLMAINTNNACERTIFICATEOFCONSEMTOSELF-INSUHEFORWORKERS' _
� COMPENSATION,AS PROVIDED BV SECTION J70o OF 7NE UBOR CODE,FOR THE PERFORMANCE w
OF hIE WORK FOR NM111CH THIS PERMI7 IS ISSUED. �
�
w 1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SEC710N /�.� •�y/1
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS �Vv- �j ee Y
ISSUED.MY WORNERS'COMPENSA710N INSURANCE CARRIER AND 70l.ICY NUMBER ARE: CONSTRUCTION � � 1 11� l7 U
jcnaaiea PLAN REVIEW • i w/�\ I�I I 1�
� PIX.ICVNUMBER ELECTRIC u by�„_
, � (IYtlSSECi1CNNE�NOTBE00R�lETEDOFiHEPEFiAffISFORONEFilRi7REDDOILIRS(f100)OqLESS} PLUMBING nf�flN
w (�Q'�j J L,uv�
Z I CEHTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI7 IS ISSUED.I MECHANICAL G'P 17 U G.r
C}' SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TO THE
Vj WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGHEE THAT IF I SHOULD BECAME INSPECTION FEE • �"! ��� ����
SU&IECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR ` � �l y (�,�i
O CODE,I SHALL FORTHWI7H COMPLY WIT/THOSE PROVISIONS. ISSUANCE /'� AATT��Yu�1
lUu� a,��
p DATE: APPUCANT: SMIP 1
w ENERGY P/C
J WARNINO:FAILURE TO SECURE WORKEPS'COMPENSA710N COVERAGE IS UNUWFUL,AND SHALL BE �
� SUBJECTANEMPLOYER70CRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENEAGYPERMIT
DOlURS(f1o0,000),IN ADDITION TO7HE COST OF COMPENSATION,DAMAGES AS PiiOV10ED FOR IN L�
� SECTION 3708 OF THE UBOR CODE,INTEREST,AND ATTORNEI"S FEES. RETENTION FEE: � �
d CONSTFUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PENALTV OF PERJURY THA7 THERE IS A CONS7RUCTION IENDING AGENCY
a- fOR THE PERWRMANCE OF THE WORK FOR WHICH THIS PERMIT I5ISSUED(SEC.3oB7,CIV.C.).
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� IENDER'S NAME
f- LENDER'SADDRESS
w 1 CEHTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES i 4�/��• �.
� 1 AGHEE TO COMPLV N7TH ALL CT'AND COUNTY ORDINANCES AND STATE UWS REUTING 70 BUILDING � �' �
CONS7FUCTION,AND HEREBV AU7HORIZE REPRESENTATIVES OF 7HIS COUNTY 70 ENTER UPON THE
ZABOVE- EN710NED PROPER7V FOH INSPEC710N PURPOSES. COMMENTS
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� NAT E OF PERMtTTEE D TE
� RECPT.NO. .PAID BY � VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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GROUND PLUMBING � UNDER FLOOR CUMDUIT j
SLAB GRADE FIREf'LACE FOUNDRTION
TEMP POWER � FIREPLACE BONQ BEAM
WATER SERVICE �MID HT. BOND BEAM � �
ROOF SHEATHING 8 FT'. BOND BEAM !
FRAMINGNENTILIATIdN FINAL BOND BEAM �i �
ROOF COVFR PRE-GRADING
i�OUGH HEATING BENCHING J �
F30UGN EL�CTREC ROUGH GRADING
ROUGH P�UiVIBWG FINISH GRADING �
SHOWER/TUB TEST � POOL ELECTRIC •
EXT. LATH/SIDING. POOL FENCING
�NRLL lNSULAl'ION POOL FINAL �
uEILitVG II�SULATION � OFF SITE 1MPS. ;
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SEV�JER FINAL ENG.
SEPTIC TAfVK LANDSCAPE/IRRIG.
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FIPl.AL HE�TING_ � HEAI_TH DEPT. FINAL_, ^
� Fii�A�_ELECTRIC � DEV. FEES FAID
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