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_��� CITY OF DIAMOND BAR EXPIF�E[7
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
, 21660 E.Copley Drive Suite 190 JUN 17 Z001 PRESS �
(909)86Q3195 Fax(909)861-3117
���'�^'� BUII.DING PERMIT APPLICATION FIRMLY
o ADDRESS�I.JZs ��U�.1'Yr �' G� DATE'CATION j ���I NUMB R #/C
c� ISSUE TYPE OCC
� APN LOT TRACT DATE CONST. GROUP
p OWNER � i A� V�j�e S
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Z CITY �� ZIP /76 S TEL. /`�-FI�I ZS`� FRONT RW ❑
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N DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
¢ OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFlRY UNDER VENPL7Y OF PERNRY THAT�AM EXEMPT FROM THE CONTRACTORS LI- G8�89B/CBfpOR
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o31.58USINESSANDPROFESSIONSCODE:ANVCITVOR (n
U COUHfYWHIpiREWIRESAPERMRTOCONSTHUCT,ALTERIMPROVE.DEMOLISH,ORREPAIRANVSTRUC- W P81i0/DBCk
� TURE,PRqR TO ITS ISSUANCE,ALSO REW IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
STATEMENT THAT HE OR SHE IS LJCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � P�OVSpe
FESSpNS OODE)OR THAT HE OR SHE IS EXEMP77HEREFHOM AND THE BASIS FOR THEALLEOED E%EMP-
TION.ANYVIOLATIONOFSECTION7031.58YANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof ,j�O
� A CIVIL PENAL7Y OF NOT MORE T1AN FIVE HUNDRED DOLURS(i5o0).):
� OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOM7ENSATION, � COR1mefClel �
MALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED fOR SALE(SEC.70��,B1151- J
N NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PHOVEHTY NM1iO BUILDS OR IMPqOVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� THqOUGH HIS OH HER ONM EMPLOVEES,PROVIDED 7HA7 SUCH IMPHOVEMENTS AHE NOT INTENDED OR m
OOFFEREDFORSALEIF,FIOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE�
Z �TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR ,
� IMPROVE FOR TME PURPOSE OF SAIE).
w ❑I,ASOWNEROFTHEPROPERfY,AMEKCLU51VElYCANTMCTINOWfTHLICENSEDCONTMCTORS
� TO CONSTRUCT TNE FROJECT(SEC.7041,BUSINESS AND PROFESSIONS CODE:THE CONTRAC70R5 U- V81UetlOfl ADJ.AREA
W CENSE UW DOES NOTAPPLV TOAN OWNER OF A PROPER7V WHO BUILDS OR IMPROVES THEREON,AND
� WHOCONTMCTSFORSUCHPROJECTSWIhIACONTRACTOR(S)LICENSEDPURSUAHTTOTHECONTRAG �UANTITY DESCRIPTION FEE
� TORS IJCENSE UW.).
O AM�E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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DATE ONMER_ �
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� LICENSED CONTRACTORS DECLAAATION w
� I HEREBY AFFIRM UNDER PENALTV OF PERIURY THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER �
� D(COMMEHCINO WI7H SECTION 7000)OF DIVISION 9 OF THE BUSINESS AND PROFESSIONS CAOE.AN� Z
W LICENSE IS IN FULL FOPCE M!D EFFECT.
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� LICENSE CLASS LIC.NO. j
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V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q �
� I HEHEBV AFFIRM UNDER PENALTY OF PERIURV ONE OF THE fOLLOWING DECURATIONS: �
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0 I HAVE AND WILL MAINTAIN A CERTIFICATE oF CONSEN7 TO SELF-INSURE FOR WORKERS' 2
� COMPENSATION,AS PROVIDED BV SEC710N 770o OF THE LABOq CODE,FOR THE PERFORMANCE �U
OF T1E WORN FOR NM1iIGi THIS PERMIT IS ISSUED. � .
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w _1 HAVE AND WILL MAIMAIN WORKERS'COMPENSA710N INSURANCE,AS REOUIRED BY SEC710N �l � /\
Q 37000F TME LABOR CODE,FOR T1E PERFOHMANCE OF THE WORK FOR WHICH THIS 7ERMIT IS � \ �l `
ISSUED.MY WORKERS'COMPENSATION INSURANCE CAFRIEN AND POLICY NUMBER ARE: CONSTRUCTION �� � v
� CAPRIER PLAN REVIEW
Z POLICV NUMBER ELECTRIC
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� (IWSSEc,'fpNr�lE�Nor8Eo7A4'LE7EDOF7ViEPEaARISFORONEHIR�DaEOWLLAPSK100)OR�Essl PLUMBING
Z I CERTIFY h1AT IN 7HE PERFORMANCE OF 7HE WOHK FOR WHICH THIS PEHMI7151SSUED,I MECHANICAL
('} SNALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECAME SUBJECT TO THE �
� WORKEHS'COMPENSA710N LAWS OP CALIFORNIq AND AGPEE TMAT IF I SHOULD BECOME INSPECTION FEE - - __ ,
SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE UBOR ^
� CODE,ISHALLFOHTHWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCE �0�+
� SMIP •S
p OATE: APPLICANT. .
J WARNINO:FAILURE TO SECUHE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SU&IECTIN EMPIOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMI
DOLLARS(S1a0,00o1,IN ADDITION TO THE COST Of COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF 7HE UBOR CODE,INTEHEST,AND ATTORNEV'S FEES. RETENTION FEE: �
2
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PERIURY THAT THERE IS A CONSTRUCTIOH LENDING AGENCY
FOR THE FERFORMMICE OF THE WORK FOR WHICH 7HI5 PEFMIT IS ISSUE�(SEC.7097,CIV.C.). .
Z
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� LENDEH'S NAME �
F- LENDER'SADDRESS
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMIITION IS CORRECT. TOTAL FEES � �.�(�.
w I AGREE TO CAMPLV WITH ALL CI7Y AND COUNTY ORDINANCES AND STA7E L4W5 REUTING TO BUILDING � '
� CONS7RUCTION,AN�HEREBV AU7F10RIZE REPRESENTA71VE5 OF THIS COUNTV 70 EN7ER UPON THE
ZABOVE•MENTIONED VROPER7V FOR INSPECTION PURPoSES. COMMENTS
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� RECPT.NO. � PAID BY , VALIDATION
WHITE—Depertment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENR D--File Copy,GREEN—Applicant Copy
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SLAB GRADE FIREPLACE'FOUNQATION ___ •
TEMP POWER • FIREPLACE BOND BEAM
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ROOF SHEATHING 'U�C-O 8 FT. BOND BEAM � _
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