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C1TY OF DIAMOND BAR
----��`-- DEPARTMENT OF COMMLTNTTY 8c DEVELOPMENT SERVICES
� 21825 E.Copley Drive PRESS
(909)860-3195 Fax(909)861-3117
`':9,:�''W BUILDING PERMTT APPLICATION IRMLY
� J08S1TE /� ' �j�.__L_ .. APPLICATION I^ I � � PERMIT � PiC
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p I HEREBV AFFIRM UNDER PENALTV OF PEfL0.1RV THAT I AM EXEMPT FROM THE CONTRACTORS LI- GefBJB/CBfPOft
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� TURE.PRIOR TO ITS ISSUANCE.ALSO REOUIRES 7HE APPLICANT FOR SUCN PERMIT TO FILE A SIONED w
� STATEMENT THAT HE OR SHE IS IJCENSEO PUFSUANT TO THE PROYISIONS OF THE CONTMCTORS LI� � POOUSp2
� CENSE LAW(CHAPTER Y(COMMENCINO WITM SECTION 700a)OF DIVISION 3 OF iHE BUSINE55 AND PRO-
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TION.ANV VIOLATqN OF SECTION 7031.6 BY ANY�PPUCANT FOR A PERMIT SU&lECTS THE APPIICANT TO Z Re-Roof
� A CML PENALTY OF NOT MORE 7HAN FIVE HUNORED DOlLARS(5600�.): _
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Z WILI DO THE WORIC AND THE STRUGNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7041,BU51� J
' � NE55 AND PFOFESSIONS CODE:THE CONTFACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF �
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[[ 7HROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCMIMPROVEMENTSARENOTINTENDEDOR
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Z TION,THE OWNER�BUILDER YALL MAVE THE BURDEN OF PROVINQ THAT HE OR SHE DID NOT BUIID OR
� IMPROVE FOP THE PURPOSE OF SALE).
❑I,AS OWNEH OF THE PFiOPERTY,AM E)CCLUSIVELV CANTqACTINO WITM LICENSED CONTiUCTORS
� TO CONSTRUCT THE PROJECT(SEC.70N,BUSME55 AND PROFESSIONS CODE:THE CONTRACTORS U- V8IU2fIOf1 ADJ.AREA
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QI HEREBV AFFIRM UNDER PENAL7Y OF PERJURV 7HAT I AM LICENSED UNDER PRO�ISIONS OF GiAPTER � � �r
p„ Y(COMMENCINO WITM SECTION 7oa0)OF DIVISION 30FTHE BUSINESSAN�PROFESSIONS COOE,AND Z
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� WOFKERS'COMPENSATION DECLARATION � S
� I HEREBYAFFIRM UNDER PENALTV OF PERIURY ONE OFTHE FOLLOWINO DECURATIONS: '
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� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEM TO SELF-INSURE FOR WORNERS' 2
� COMPENSATION,ASPROVIDEDBVSECTION37000FTHELABORCODE,FORTHEPERFORMANCE W
OF THE WORI(FOH WHICH TMfS PEAMIT IS�SSVEO. �
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W �I HAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
O 3700 0F TME LABOR CADE.FOR THE PERFORMANCE OF iNE WORN FOR WHILH THIS PERMIT 15 CONSTRUCTION
ISSUED.M'V--�IOFiKEjiS'CO��SATION INSURANCE CARRIER�ND 70lICV NUMBER ARE: ,
j �5 y�y�.' PLAN REVIEW
CARRIER /�T�l 1 K
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Z I CEHTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
(} SHALL NOT EMPLOYANV PERSON M ANY MANNER SOAS TO BECAME SU&IECTTOTHE
N WORKERS'COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHWLD BECAME INSPECTION FEE
� SU&IECT TO TNE WORNERS'CAMPENSATION VROVISIONS OF SECTtON 3'1000F THE LABOR ISSUANCE
� CODE 1 SM ORTFM/ITH COMPLV WITH THOSE PROVISIONS.
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p DATE: "� a AP%.ICANT: .
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J WARNINO:FAI�URE TO SECURE WOFKERS'CO NSATION COVERPGE IS UNUWFUI.AND SHALl9E
� SU&IECTAN EMPLOVER TO CFIMMAL PENALTIES AND CNIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
OOLLARS(f100.0001,IN ADDITION TO THE COST OF CAMPENSATION,OAMAGES AS PROVIDED FOR IN
J SECTION 3�00 OF THE LABOR CODE,INTEREST,�ND ATTORNE�"5 FEES. RETENTION FEE: �"�- -
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w CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HERE9V AFFIRM UNDER PENALTY OF PERIURV THAT THERE IS A CONSTNUCTION LENOINO AGENCV
d FOR 7HE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT 151SSUED�SEC.3087,CIV.C.). '
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wI CERTIFV TNAT I HAVE READ THIS APPLICATION AND STATE THAT THE�BOVE INFORMATION IS CORRECT. TOTAL F E ES �� -7� ��
� I AGREE TO COMPLV WITH ALL CITV AND COUNTY ORDINANCES AND STATE UWS REIATING TO BUILDING � � � �
CONSTRUCTION,AND HEREBY AUTHORIZE AEPRESENTATIVES OF THIS CAUNTY TO ENTER UPON THE
ZABOVE�MENTIONEO PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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RECPT.NO. PAID BY VALIDATION
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�' WHITE—DeDertment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENFO�FI�e Copy.GREEN—Applicant's Copy
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SLAB GRADE FIREPLACF FOUNDATION��
TEMP POWER FIREP�ACE BONQ BEAM �
W/�TER SERVICE MID HT. BOND BEAM .
ROOF SHEATHING _ 8 F�f: BON.G;BEAM
FRAMIMGNENTILIATION FINAL 80IJD BEAM
ROOF COVER PRE-GRADING
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ROUGH ELECTRIC R�UGH GRADING
ROUGH PLUPJiBING ���/?��— FINISH GRADING „
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WALL INSULATION POOL FINAL ��
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DRYWALL iVAILING DEDICATIUNS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IARlC,.
SEEP P1TlI�.L. ON SITE IN1PS.
GAS AIR TEST � FINAL ZONING
FINAL CONST. F�RE DEPT. FINAL
F1NAL HEATING HEALTH DEPT. FINAL
FI�aAL ELECTRIC DEV. FEES PAID
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