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�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES Q�l 2 51002
21660 E.Copley Drive Suite 190
(909)860-3195 Fau(909)861-3117 PRESS
��-���� BUILDING PERMIT APPLICATION • FIRMLY
y�, JOBSITE �p� " i,� APPLICATION � �1 iG/ PERMIT � PfE
o ADDRESS ����� N�v�i�t�1 M `�"3 R�,-W� � DATE � � � NUMBER a
c.� � � ISSUE TYPE OCC
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`L ADDRESS 2� Ov u ,, ZONING SEfBACKS
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� OWNER-BUILDER DECLARATION SFR/ADD/REM
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0 I HEREBV AFFlRM UNDER PENALTY OF PERIURY THAT I AM EXEMV7 FROM 7HE CONTRACTORS LI- � Garage/Carport �
W CENSEUWFORTHEFOLLOWINOREASON�SEC.7031.6BUSINESSANDPROFESSIONSCODE:ANVCITYOR
U COUHfYMMICHREOUIHESAPERMRTOCONSTRUCT,ALTER.IMPHOVE,DEMOLJSH,ORREPAIHANVSTRUG W PdllO/DBCk
Z TURE.PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICAHT FOR SUCH PERMIT TO FILE A SIC,NED w
, � STATEMEHT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTMCTORS ll�
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PRO- � PooVSpa
FESSIONSCOOE)OHTHATHEORSHEISEXEMPTTHEREFROMAND7HEBASISFORTHEALLEC,EDEXEMP� � �
TION.ANYVIOLATIONOFSECTION7a11.6BVANVAPPLICANTFORAPERMITSU9IECTSTHEAPPLICANTTO Re-Roof
� ACML PENALiV OF NOT MORE TMAN FNE HUNDRED DOLURS(i5oo).):
� ❑I,ASONRIEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSA710N, COrt1RIBfCi81 - l
WILL DO THE WORIC AND THE STRUCTURE IS NOT INTENDED OH OFFERED FOR SALE(SEC.7ou,BU51- J
NESS AND PROFESSIONS CODE:7HE CONTRACTORS LICENSE UW DOES NOT AGPLV TO AN OWNER OF
N PipPERTYYVFIOBURD50RIMPROVESTIEREON,ANDNMODOESSUCHWORKHIMSELFORHERSELFOR �
Q tHROUGH HIS OR HER ONM EMPLOVEES,PROVIDED THAT SUCH IMPROVEMEHTS ARE NO71N7ENDED OR m
QOFFEREDFORSALEIF,HOWEVER7MEBUILDINGORIMPROVEMENTISSOIDWRHINONEYEAROFCAMPLE-
Z �•TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w ❑I,ASONMEROFTHEPROPEHf1;AME%CLUSIVELYCONTMCTINON7THLICENSEDCONiRACTORS
� TO CONSTRUCT THE PR0.IECT(SEC.7oM,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- Ve1U8110f1 ADJ.AREA
W CENSE UW DOES NOTAPPLV TO AN OWNER OF A PROPERTY Vh10 BUILDS OR IMPROVES 7HEREON,AND
� WFIOCONTRACTSFORSUCHPR0.IECTSWITHACONiMCTOR(S)LICENSEDPURSUANTTOTHECONTRAG pUANTITY DESCRIPTION FEE
� TORS LICENSE UW.).
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O ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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DATE OYMER V ,
F UCENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRAI UNDER PENKTV OF PEfUURV hIAT I AM LICENSED UNDEH PHOVISIONS OF CHAPTER �
d Y(OOIAMENCINO WfTTI SECTION 7000)OF DIVISION 3 OF THE BUSINESS PND PROFESSIONS CADE,AND Z
X MY UCENSE IS IN FULL FORCE AND EFFEC7.
� UCENSE CUSS ��� �� LIC.NO. .�� d � �
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� WORKERS'COMPENSATION DECLARATION �I� a
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECUMTIONS:
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� _I HAVE AND WILL MAINTA�N A CERTIFICATE OF CONSENT TO SELF-INSURE FOR MIORKERS' _
COMPENSATION,AS PROVIDED BY SECTON 370o OF THE LABOR CODE,FOR THE PERFORMANCE U
� OFyiE WORK FOR NM1IICH THIS PERMIT IS ISSUED. �
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_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REDUIRED BV SECTION
Q 37000F THE IABOR CODE.FOR T1E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS �
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBEH ARE: CONSTRUCTION
� CARRIER �j�. 1�T�. �N II� I � PLAN REVIEW
� POIiCV NUMBER �O.�iG4 �.�� ( � � �� ELECTRIC
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� (nasSEcna+r�IDra7sEoo�E7moF7r��aMrswaawEMirna�oaiaas�iro)at�ss} PLUMBING
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Z I CERTIFY THA7IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PERMI715ISSUED,I MECHANICAL V 1 rI 1 ANn
(,�} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE '����9 /� / \
� WORKERS'COMPENSATION UWS OF CALIFORNIq AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE �p$� ''/ i �rn ) �
S SUBJECT70 THE WORKERS'CAMPENSATION PROVISIONS OF SECTION 3700 0F THE LABOR 1�ay Q� ��
cooE,i sHui Foan+wini coMv�v win�n�osE raovisioras. ISSUANCE i�r
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p DATE:�..I-1'1 —�► K APPLICANT. 5����,�� �-p .
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J WMNINO:FAILUHE TO SECURE WORKERS'CAMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
�y SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDHED THOUSAND ENERGY PERMIT
DOLURS(i7o0,000),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIOED FOR IN
J SECTpN 3708 OF 7HE LABOR CODE,INTEREST,AND A7TOHNEV'S FEES. RETENTION FEE:
Q
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBY AFFIfiM UNDER PENALTY OF PERIURV THAT THERE IS ACANSTRUCTION LENDING AGENCV
FOR THE PERFOHMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUEO(SEC.�087,CIV.C.).
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� LENDER'S NAME
H IENDER'SADDRESS
� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHA77HEABOVEINFORMATIOD115CORHECL TOTAL FEES � �
W I AGRE�TO COMPLY N7TH ALl CT'M1D COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTFiORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON 7HE
ZE-MENTIONED PROPER7Y FOR INSPECTION PURPOSES. COMMENTS
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SIO TUREOFPERM�EE� • � DATE �
� RECPT.NO. PAID BY � VALIDATION
� WHITE-0epartment Copy,YELLOW--Finance Capy,PINK—Assessor Copy,GOLD NROD--File Copy,GREEN—Applicant's Copy t. �
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FTGS/FORMS/STEEL FHA FiEQMTS
ELECTRIC GROUND UNDER FLOOR DUCT '
GROUND PLUMBING UNDER FLQOR CU�IDUIT .
SLAB GRADE FIREPLACE•FOUNDATION •• • • '
��TEMP POWER FIREPLACE BOND BEAM ' " � ' ' '
� WA7Ep SERVICE MID HT. BOND�BEAM— ' - • ; �
ROOFSHEATHING `I(-a�=`(� � � � — 8 FT. B.OND BEAM _ • � �
FRAMINGNENTILIATIOtJ FINAL BOND BEAM ;
ROOF C�VER PRE-GRADING ;
ROUGH HEATING BENCHING �
AOUGH ELECTRIC ROUGH GRADING �
ROUGH PLUMBING FINISH GRADING �
SHOWER/TUB TEST POOL ELECTRlC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION • POOL FINAL
CEILING INSU�ATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TAR1K _ LANDSCAPE/IRRIG. '
SEEP PIT/L.L. � � " ON SITE IMPS.
GAS AIR TEST � FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELEGTRIC DEV. FEES PAID
FINAL PLUMBING ENERGY
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