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���.,:. CITY OF DIAMOND BAR �
�I -- -���-— DEPARTMENT OF COrRvIUNITl'&DEVELOPIvfENT SERVICES
21825 E.Copley Drive PRESS
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".�;�'�W BUILDING PERMTT APPLICATION FIRMLY
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I� APN LOT TRACT DATE � V CONST. GROUP
� OWNER
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� ADDRESS PROPOSED USE
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DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAUfATiON
� OWNER-BUILDER DECLAAATION SFFUADD/REM
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I HEREBV AFFlRM UNDER PENALTV OF PERIURY TF1AT�N.1 E%EMPT FROM THE CONTRACTORS LI� G8f8QB/CBf�IOR
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W GENSE LAW FOR THE FOLLOWINO REASON(SEC.�031.5 BUSINESSAN�PROFESSIONS CO�E:ANY CITV OR .
U COUNTVWHICHREWIRESAPERMITTOCONSTRUCT,ALTERIMPROVE.DEMOLISH,ORREPAIRANVSTRUC- W P8�10/DBGI(
WTURE,PRqR TO ITS ISSUANCE,ALSO FEOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
� STATEM£NT YHAT HE OR SHE 15 LICENSED NASUANT TO TME PROVtS10N5 OF THE CONTqACTORS LI� � POOUSp2
� CENSE LAW(CMAPTER G(COMMENCINO WITH SEGTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO�
O FESSIONSCOO�ORh1ATHEORSHEISE%EMPTTHEREfROMANDTHEBASISFORTHEALLEdEDE%EMP-
U TION.ANVVqLATIONOFSECTION7071.5BVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOlURS(f600)J: _
O ❑I,ASOWNEROFTNEPROPERTY.ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COf11f110fC�81
Z WILL DO7HE�NORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR S/�LE(SEC.70a�,BUSI� J
N NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF �
VROPERTVWHOBUILDSORIMPROVESTNEREON,ANDWHODOESSUCHWORKHIMSEIFORHERSELFOR m
a 7NqOUGH HIS OR HER ON?J EMPLOYEES,PROVIDED THAT SUCFI IMPROVEMENTS ARE NOT INTENDED OR
W OFFEREDFORSALEIF,HOWEVE0.TNEBUILDINGOHIMPROVEA/ENTISSOLOWfTHINONE�EAROFCOMPLE-
� TION,7HE OWNEF�BUILDER WILL MAVE 7HE BURDEN OF PROVINO YHAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FON THE PURPOSE Of SALE�.
_ ❑I,ASOVMEHOFTHEPROPEfiTY,AMEXClUSNELYCONTFACTINOWfTNLICENSEDCONTRACTORS
Q TO CONSTRUCT THE PR0.IECT(SEC.704/,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI� VeIl18fIOf1 ADJ.AREA
W CENSELAWDOESNOTMPLYTOANOWNEROFAPHOPERTVWHOBUILDSOHIMPROVESTHEREON,AND
� WFIOCONTMCTSFORSUCHPR0.IECTSWITHACONTRACTOH(S)LICENSEDPURSUANTTOTMECONTNhG OUANTITY DES IPTION FEE
TORS UCENSELAW.).
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� O I AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON U <
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� LICENSED CONTRACTORS DECLARATION -�
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1 HEHEB��FFIRM UNDER PENALTY OF PERJURV THAT I11M LICENSED UNDER PROVISIONS OF CHAPTER Ur
p_, Y(COMMENCINO WITH SECTION 7000)OF DIVISqN J OF 7HE BUSINE55 AND PROFESSIONS CODE.AND Z
X MY LICENSE IS IN FULL FORCE AND EFFEC7. m
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� LICENSE CLASS LIC.NO. J
V DATE GIXJTRACTOR a
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� WORKERS'COMPENSATION DECLARATION • J .
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� I HERFBV AFFIRM UNDER PENPLTV OF PERIURV ONE OF TNE FOLLOWINQ DECIARATIONS: Z
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� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR V+ORNERS' 2
Q COMPENSATION,AS PROVIDEO BV SECTION�700 OF THE LABOR CODE.FOR THE PERFORMANCE w
OF THE WOf1K FOR YAiICH TNIS PERMIT IS ISSUED. �
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w _I HAVE AND WILL MAINTAW WORKERS'COI.IPENSATION INSURANCE,AS REQUIRED BV SECTION -
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WOFN FOR WHICH THIS PERMIT IS � `�
� ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION
� CARRIER PLAN REVIEW
Z aouCrNUMaEa _ELECTRIC
Q ([HlSSECTqNNE�NOTBEO�NIPLErEDOFhEPE�6FOR�NEF�,N�DREDD�LIARS(S�WI�LESSl � PLUMBING
w I CEFiTIFY THAT W THE PERFORIAANCE OF THE N'ORK FOR WHIG1 THIS PERMIT IS ISSUED,I MECH NICAL
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�J SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO 9ECOME SUBJECT TO THE N ECTION FEE -' ,-�--
� WORNERS'COMPENSATION LAWS OF CAUFORNIA.AND AGREE THAT IF I SMOUL�BECOME
� SU&IECTTO THE WORNERS'COMFENSATION PROVISIONS OF SECTION 3700 OF THE 1A80R I SUA ��S
� CODE.I SHALL FORTHWITH CW.�PLV WITH THOSE PROVISIONS. t�
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p DA7E: APPLICANT: .
� ENERGY P/C
WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL 6E
� SU&IECTANEMPLOVERTOCFIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOU5AN0 E
OOLLARS(5100.000l.IN ADDITION TO THE COST OF COMPENSATION,ON.IAGES AS PROV�DED f-0R IN /�
J SECTION 37DB OF THE LABOR COOE.iNTEREST.AND ATTORNEV'S FEES. �n� �CC•
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURY THAT 7HERE IS A CANSTRUCTION LENDINa AOENCY
�- FOF TNE PERFORMANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUED�SEC.J097,pV.C.). '
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�S LENDER'S NAME
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F- LENDEfi'S ADORE55
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TNE ABOVE INFORMATtON IS CORRECT.
TOTAL FEES ''
w I AGREE TO COMPLY WITN ALL pTV AND CAUNTY ORDINANCES AND STATE UWS RELATING TO BUILDINO
� CANSTRUCTFON,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS 70 ENTER UPON THE
Z ABO � ENTIONEO PAOPERN FOR INSPECTION PURPOSES.
COMMENTS
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m P ITT E NAME(PRINT) .
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N i NATUREOF PEFlMITfEE DATE RECPT.NO. PAID BY VALIDATION
� WHITE—Depariment Copy,YEILOW—Fi�ance Copy,PINK—Assessor Copy,GOLDENROo--File Copy,GREEN—Applicant's Copy
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SET BACK � ' � FLOOR Jb1ST ',
FTGSIFORMS/STEEL ; FHA RECIMTS �
ELECTRIG GROUND ' UNDER FL�OR DUCT .
GROUND PLUMBING ` UNDER FLOOR CU(�{DUIT -
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER �IREPLACE BOP4a BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING 8 FT. BOND BEAM i
FRAMIIVGNENTILIATiON ��� F'INAL BOND BEAM
ROOF COVER PRE-GRADING �
ROUGH HEATING BENCHING
ROUGH ELECTRIC F10UGH GRADI�VG
ROUGH PLUNIBING FINISH GRADiNG
SHOWER/TUB TEST I PUOI ELECTRIC
EXT. LATH/SIdING POUI FENGNG
WALL INSULATION I POOL FINAL '
CEILING 1NSULATION I OFF SITE {MPS.
DR`M/ALL tVAILING DEDICATIONS
SEWER FINAL ENG. "
SEPTiC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. u C7N 51TE IMPS.
GAS AIR TEST � FINAL ZONiNG
F1NAL CONST. �l� /�j�,-/� � . FlRE dEPT. FINA�
FfNAL HEATING HEALTH dEPT. FINAL
F1NAL ELECTRIC ���I�� �j,/¢� DEV. FEES PAID
FINAL PLUMBING ENERGY
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