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�f� CITY OF DIAMOND BAR {""
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
W ,� 21660 E.Copley Drive Suite 190
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������ BUII.DING PERMIT APPLICATION FIRMLY
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� APN LOT��� TRACT ' DATE �' � --1� CONST. GROUP
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� DESIGNER J•� • M�• NO.DWEL. NO. NO.
ADDRESS � UNITS � STORIES �� BEDROOMS
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� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� I HEREBY AFFlRM UNDER PENALTV OF PERIURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- GefBQB/CBtPOA
W CENSEUWFORTHEFOLLOWINOREASON(SEC.7o31.5BUSINESSANDPROFE5S10NSCODE:ANYCITYOR , (n
U COU!lfYNMICMRE0UIRESAFERMRTOCONSTRUCT,�LTERIMPFOVE,DEMOLISH,ORREPAIRANVS7AUC- W Patio/Deck -
Z TURE,VRIOR TO ITS ISSUANCE,ALSO RE-0UIRES THE APPLICMIT FOR SUCH PERMIT TO FI�E A SIGNED
�� STATEMENT THAT HE OR SHE IS LICENSED PURSUAM TO 7HE PROVISIONS OF THE CONTMCTORS LI- w
� CENSE UW(CHAPTER D(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF TME BUSINESS AND PRO• LL' PooUSpa
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM ANO THE BASIS FOR 7HE ALLEOED EXEMP-
TIOH.ANY VKK.ATION OF SECTIOH 70J1.S BYANYAPPLICANT FOR A VERMIT SUBJECTS 7HE APPLICANT T0 Z Re-Roof
� ACML PENAL7Y OF NOT MORE THAN FNE HUNDRED DOLLARS(i�0).):
� ❑I,ASONMEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSA710N, 0 Commerciat —
WILL DO THE WORK AND THE STRUCTUHE�S NOT IMENDED OR OFFERED FOR SALE(SEC.70M,BU51� J
NESS AND 7iqFESSIONS CODE:iHE CONTMCTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF
N PROPEHTYNRiDBUODSORIMPROVESTHEREON,ANDNTIODOESSUCHWORNHIMSELFORHEHSEIFOq �
Q THiqUGHNI50RMEROWNEGPLOYEES,VROVIDEDTHATSUCHIMPROVEMEHTSARENOTINTENDEDOR m �
� ,OFFERmFOR3AlEIF,lIOWEVEF�THEBUItDINUORIMPROVEMENTI550LDWfTHINONEVEAROFCOMPIE-
Z `TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIID OR
� W PipNE FOR TIiE PUHPOSE OF SALE).
❑1,AS OWNER OF THE PROPEHf1;AM EJCCLUSNELY CONTfUCTINd WfTH UCENSED COHTRACTORS
Q TO CONSTRUCT THE PRQIECT(SEC.70la,BUSINESS AND PROFESSIONS CODE:THE CONTMC70HS LI• VelUatlOfl ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANONMEROFAPROPERTYWHOBUIIDSORIMPROVESTHEREON.AND �
� WIqCONTRACTSFORSUCHPR0.IECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG pUANTITY DESCRIPTION FEE
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� O I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS HEASON U
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� DATE ONMER �
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F LICENSED CONTRACTORS DECLARATION W
� I HEREBYAFFIRAI UNDER PENKTV OF VEfUURV TNAT I AM LICENSED UNDER PHOVISIONS OF CHAPTER � y i„-�:J _ �
� Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BU�INE55 AND PROFESSIONS CODE,AND Z
�� W IICENSE IS IN NLL FORCE AND EFFECT.
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� UCENSECLASS UC.NO. J �.A�� �� . ���(�
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� WORKERS'COMPENSATION DECLARATION Q Ld:l d VS' ���"v-`�C e�TX
� I HEREBV AFfIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLAWING DECURATIONS: Z L��-+���� ��� V
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� IMAVEANDWILLM/UNTAINACEFfIFlCATEOFCONSEHTTOSEIF-INSUREFORWORKERS' 2
� COAIPENSATION,AS PROVIDED BV SECTION 370o OF THE UBOR CODE,FOR 7HE PERFORMANCE W
OF THE WORK FOR WHipl Tl/15 PERMIT IS ISSUED. �
�
_I HAVE M1D WILL AWNTAIN WORKERS'COMPENSATION INSUFiANCE,AS REOUIRED BY SECTION
Q 9700 OF THE LABOR CODE,FOR TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION � I I O
jc�aaiEa PLAN REVIEW t
� POLICV NUMBER ELECTRIC
0 �Ss�crqrrr�IDrprgE��poFn€pEqrRrsFoqor�EHtx�pampplsfs�siro)oatFss} PLUMBING
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Z I CERTIFY THAT IN THE PERWRMANCE OF hIE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL
(,�} SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECAME SUBJECT TO THE .
� WORKERS'CAMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE
S SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SEC710N 370o OF THE LABOR ISSUANCE ��� ��
CODE,I SHALL FORTHWI7H CAMPLV WITN iHOSE PROVISIONS.
p DATE: � APPLICANT: " SMIP /�� d,
w ENERGY P/C
J WMNIHO:FAILUflE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
� SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(S70o.o00),IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 97oa OF THE LABOR CODE,IN7EREST,AND ATfORNEY'S FEES. � RETENTION FEE:
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d CONSTRUCTION LENDING AGENCY PR�qL�EE: -
� I HEREBV AFFIRM UNDER PENALTV OF PERIURY THAT THERE IS A CONSTRUCTION LENDING AGENCV I ��L
FOR THE PERFORMANCE OF TiE WORK WR WHICH THIS PERMIT IS ISSUED(SEC.3077.CIV.C.).
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� LENDER'S NAME �� r u
F— LENDER'SADDRE55
� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETUTTiEABOVEINFORMATIONISCORHEC7. TOTAL FEES
w 1 AGREE TO COM7LV N7TH ALL CfTV AND COUHTY ORDINANCES AND STATE UWS RELA7INO 70 BUILDING
� CONS7RUCTION,AND HEREBV AU7NORIZE REPRESENTATIVES OF 7HI5 COUNTY TO EMER UPON THE �
ZABOVE-MEHTIONEDPROVER7YFORINS crar+auaaoses. COMMENTS ' �
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� SIONANRE OF RM DATE
� RECPT.NO. PAID BY � ALIDATIO
WHITE—Depertment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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SET BACK N , ,, - FLOOR JOIST � ,`, . `'� .;� t `�'.;ti'�
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FTGS/FORMS/STEEL ,, , FHA REQMTS �
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SLAB GRADE FIREPL,Q. FOUNDATI(�N '�� �'• �� � �•� •'_
TEMP POWER FIREPL�G�E B �D- �AM � � � � � �� � �
WATER SERVICE MID HT. BUND BEAM
,RObF�HEA�';. . �.'.;''.�" . .:< <,-;�:• �. P :._T.�..`, 8 FT. BOND BEAM
FRAMINGNENTILIATION � � � FINAL BOND BEAM �:
ROOFCOVER `.` PRE-GRADI�G'�I ,;�; "r.. ,�.�,��.� ���' .�, ;,,.:;,.
ROUGH HEATING BENC 1 ��' I��;�� a�; .�;....^ .��.� ��.e:�:�:it�`��s'_:
ROUGH ELECTRIC � ROUGH GRADING
ROUGH PLUMBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC �
EXT. LATH/SIDING POOL FENCING •
WALL INSULATION POOI FINAL
CEIUNG INSULATION OFF Sll'E IMPS.
DRYWALL NAIUNG DEDICATIONS '
SEWER F1NAL ENG.
SEPTIC TANK _ ti LANDSCAPE/IRRIG.
SEEP PIT/�.L. ' ' '' \�" � ON SITE IMPS.
GAS AtR TEST FINAL ZONING
FINAL CONST.� � � � FIRE QEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FIfVAL PLUMBING ENERGY
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