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i _1�,�,`1_ CITY OF DIAMOND BAR � ��
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-70 PRESS
4'°^'. BUILDING PERMIT APPLICATION - FIRMLY
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO REW IqES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w P81I0/DBCIC
W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(CHAPTER D(COMMENCINO WITH SECTKKJ 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOUSPB
� FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIS FOR THE ALLEOED E%EMP• (�
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A CIVIL�ENALTY OF NOT MORE hIAN FIVE HUNDRED DOLURS(5500�.):
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Z WIIL DO THE WORI(AND 7HE STRUCTURE IS NOT INTENDED Ofl OFFEREO FOR SALE(SEC.7a�,BU51� J
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PROPEHTV WHO BUILAS OR IMPROVES THEREON,AND YM1iO OOES SUCH WORK HIAISELF OR HERSELF OR
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I HEHEBV AFFIRM UNDER PENALTY OF PERJURY THAT I AM UCENSED UNDER PROVISIONS OF CHAPTER � ��
� 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z �
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� WORKERS'COMPENSATION DECLARATION � Q 1�`_S�i
� I HERFBV AFFIRM UNDER PENALTY OF PERIUFY ONE OF TFIE FOLLOWING DECURATIONS: �
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� _I NAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORNERS' _ -
Q COMPENSATION,AS VqOVIDED BY SECTION 3�00 OF THE LABOR CADE.FOR.THE PERFORMMICE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. .j W
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� _I HAVE AND WILL MAIMAIN WORKERS'COMPENSATlON INSURANCE,AS REOUIRED BV SECTKKJ
O 37oa OF THE LABOR COOE,FOF THE PERFORMANCE OF THE WORK f-0R WHICH THIS PERMIT IS
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C} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SO AS TO BECAME SU&IECT TO THE
(/J WORNERS'COMPENSATION LAWS OF CALIFORNIq AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE
SU&1ECTT0 THE WORNERS'CAMPENSATION PROVISIONS OF SECTION 77000F THE IABOR
O CODE,ISHALLFORTHWITHCOMVLVWITHTHOSEPROVISIONS. ISSUANCE (
p DATE: APPLICANE SMIP __ G1�
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� WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C �
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AtJD CML FMES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT '3 �/�
} DOLURS(5100,000�.IN�DDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN L
J SECTION 37aB OF THE LABOq CODE.WTEREST,AND ATTORNEYS FEES.
Q RETENTION FEE: '�C5.Q O
OCONSTRUCTION�ENDING AGENCY ppF_ei T FFF. �
� I HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS A CONSTRUCTION IENDINO AGENCV jf%���� _
FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3007,CIV.CJ.
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� �ENDEfl'S NAME �;� ./�� 1�b ��C `�
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� LENDER'SADDRESS
� TOTAL FEES •�j�7Co•`�9 �t,-��� �
� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARAECT.
W I AGREE TO CqMPLV WITH AlL CITV AND COUNTV ORDINANCES AND STATE LAWS REUTINO TO BULLDINO
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� CONSTRUCTION,ANDHEREBYAUTIiORIZEREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE �
Z ABOVE-MENTIONED PROPEqTV FOR INSPECTION PURPOSES. COMMENTS '
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WHITE—Department CoDY.YELLOW�Inenoe Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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SLAB GRADE ;C.��, � FIREPLACE FOUNDATION
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WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING �0 8 FT. BOND BEAM
FRAMINGNENTILATION p-�.$Q 11 FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIdING POOL FENCING
WALL INSULATION POOL FINAL -
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING Z �,_ _k(, DEDICATIONS
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SEPTIC TANK LANDSCAPElIRRIG.
SEEP PIT/L.L. ON SITE IMPS.
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FINAL CONST. \,'� FIRE DEPT. FINAL �
FINAL HEATING �Q�,�` HEALTH�EPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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