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^ ��_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES /
_ 21660 E.Copley Drive Suite 190 j ��
(909)860-3195 Fax(909)861-3117 PRESS
`����+�*, BUILDING PERMIT APPLICATION FIRMLY
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a ADDRESS UNITS STORIES BEDROOMS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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0 I HEREBV AFFlRM UNDEH PENAL7V OF PERIURY THA7 I AM E%EMPT FROM THE CONTRACTORS LI- (�i8feg0/CBfpOR �
W CEHSEUWWRTHEFOLLOWINORF�ISON(SEC.70.71.SBUSINESSANDPROFESSIONSCOOE:ANVCITVOR (n
U COUMYWHICHREWIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W Patio/Deck
Z NRE,PRpR TO ITS ISSUANCE,ALSO REOUIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNED W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RACTORS LI-
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF�IVISION 3 OF THE BUSINESS AND PRO� � PooVSpa
FESSqNS COOE)OR THAT HE OR SHE IS EJ(EMPT TNEREFROM AND THE BA515 FOP THE ALLEGED E%EMP-
TION.ANVVIOUTIONOFSECTION7031.5BYANVAPPLICANTFOHAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� ACML PENALTV OF NOT MORE THAN FIVE HUNDREO DOLURS(i500).):
� ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COrt1rtlBfCiel �
YALL DO THE WORK,ANU THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70W,BUSI� J
NE55 NiD VROFESSIONS CODE:THE CONTMCTORS LICEHSE UW DOES NOT APPLV TO AN OWNER OF
� PipPERTI'MIFqBURD50RIMPROVESTMEREON,ANDMMODOESSUCHWORKHIMSELFOHHERSELFOH �
Q iHROUl3H HIS OR HER ONM EMPLOYEES,PROVIDED THA75Uqi IMPROVEMEMS AHE NOT INTENDED OR m
0 OFFEREDFORSALEIF,HOWEVEiLT1EBUILDINGORIMPROVEMENTISSOLDWRHINONEVEAHOFCOMPIE-
Z �TION,THE OWNER-BUIIDER WILL HAVE THE BUHOEN OF PROVIN�THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE�
O I,AS OMMER OF THE PROPEHTY.AM EXCIUSIVELY CANTRACTINO WITH LICENSED CONTRACTORS
� TO CONSTRUCT 7HE PROJECT(SEC.70M,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTOPS LI- VelUetlO� ADJ.AREA
W CENSEUWDOESNOTAPPLYTOANOWNEROFAPflOPERTYWHOBUILDSORIMPROVESTHEREON,AND
� WHOCONTRACTSFORSUCHPR0.IECTSWITHACONTMCTOR(S)LICENSEDPURSUiU1T70THECONTRAG QUANTITY DESCRIPTION FEE �
� TORS LICENSE UW.).
� ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q L I * /
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� DATE OWNER f"
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� LICENSED CONTRACTORS DECLARATION �j Qj G 1 I��TS
� I HEREBY AFFIRAI UNDER PENALTY OF PERJURV THAT 1 AM LICENSEO UNDEH PROVISIONS OF CHAPTER Ur / /.A ` S I/�
S Y(COMMENCIHO WITH SECTION t000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z V�T J I��
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V DATE IOI�I /OZ.- CONTRACTOR ��Cf1SONJ n-
� WORKERS'COMPENSATION DECLARATION � I S�,,,ytS
� 1 HEREBY AFFIRM UNDER VENALTY OF PE0.IURY ONE OFTHE FOLLOWING DECLARATIONS:
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� IHAVEANDWILLMAINTAINACERfIFICATEOFCONSENTTOSELF-INSUREFORWOHKERS' _
� COMPENSATION,AS PROVIDED BV SECTION 37a0 OF THE UBOR CODE,FOR THE PEHFORMANCE w
� OF 7HE WORN FOR WHICH THIS PERMIT IS ISSUED. �
�
W �I HAYE ANU WILL MAIMAIN WORNERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION �
Q �� 370o Of TNE LABOR CODE,FOR THE PERf-0RMANCE OF THE WORK FOR WHICH 7HI5 PEHMI715
ISSUED.MY WORKE�R7S^'COMPENSA710N INSURANCE CAR IER AND POLICY NUMBER ARE: CONSTRUCTION
� CARRIER �,�'T� �uM� PLANREVIEW
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� (iV4S5ECfICNNE�NOT8E00M�LETIDOFTfPERMfSFORONEFM�DREDOQIJ�RS(510D)ORLESS} PLUMBING
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Z I CER7IFV THAT IN h1E PERFORMANCE OF THE WORK FOR WHICH THIS 7ERMIT IS ISSUED,1 MECHANICAL
(,r} SHA:L NOT EMPLOY ANV VEHSON IN MlY MANNER 50/S TO BECOME SU&IECT TO THE �
Uj WORKERS'CAMPENSA710N UWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE �I�L-�r�Ny)�'I �--l�—An n.
S SUBJECT TO TME WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE L/�BOR _ �J � �� ��Il
CAD ,ISHALLFORTHWIhICOMPLVWITHTHOSEPROVISIONS. ISSUANCE �T.�_ �it �
p DATE:� APPLICANT. �I r���50V`� SMIP 1 OF D' �
W ENERGY P/C B DINC�,A�n r�,�......__
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHAL�BE ���
� SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDHED THOUSAND ENERGY PERMIT
DOLURS(S7ao,0o0),IN PDDITION 70 THE COST OF COMPENSATION,DAMAGES AS PHOVIDED FOR IN
J SECTION37080FTHEUBORCADE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE:
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a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEHEBV AFFIHM UNDER PENAL7Y OF PERIURV THAT THERE IS ACONSTRUCTION LENDING AGENCV
FOF THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3007,qV.C.).
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� LENDER'S NAME
H �ENDER'SADDRE55
w I CER7IFV THAT I HAVE READ THIS APVLICATION AND STATE THAT THE ABOVE INFORMATION IS CORHEC7. � TOTAL FE ES �3 �
� I AGREE TO COMPLV WITM ALL CITY AND CAUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBV AU7HORIZE REPRESEN7A71VE5 OF THIS COUNTY 70 ENiER UPON THE
Z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS �
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N SIGNA7URE OF P OATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fi�e Copy,GREEN—Applicant's Copy
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TEMP POWER � FIREPLACE BONQ BEAM
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ROUGN E�ECTRIC ROUGH GRADING
RQUGH PLUMBING ; � FiNISH GRADING '
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EXT. LATHISIDING POOL FENCING
WALL IPISULATION , POOL FINAL _
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FINA►_ELECTRIC '• ' _' ' , _: '•', � DEV. FEES PAID
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