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CITY OF DIAMOND BAR
�-�,-��` -- DEPARTMENT OF COMMUNITY&DEVELOPIvIENT SERVICES �X P I R E D
�' 21825 E.Copley Drive PRESS
'� (909)860-3195 Fax(909)861-3117 ,I U N 19 2002
`�"���� BUILDING PERIvdIT APPLICATION FIRMLY
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� ISSUE TYPE OCC
APN LOT� TRACT DATE CONST. GROUP
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w ARCH/ENG/
w DESIGNER NO.DWEL. NO. NO.
a ADDRESS
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBV AFFIfiM UNDEFi PENALTV OF PERIUFY THAT I AM EXEMPT FROM THE CON7RACTORS LI� G8f8Qe/C0lpOR
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o31.5BUSINESSANDPROFES510NSCODE:ANYCITYOR (n
U CAUN7VWHICHREOUIRESAPERMITTOCONSTRUCT,QTER,IMPROVE.DEIAOUSH,ORREPAIRANYSTRUG �
w TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIHES 7HE APPLICANT FOR SUCH PERMI7 TO FILE A SIGNED w PdllO/DBCk
S7A7EMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTORS LI�
� CENSE UW(CHAP7ER B(CAMMENCING WI7H SECTION 7000)OF DIVISION 7 OF TFIE BUSINESS AND PRO- � POOVSpe
� FESSIONS CADE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED ExEMP- (�
V TION.ANVVIOLATIONOFSECTION7031.58YANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z RB-ROOf
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
Z ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWI7HWAGESAS7NEIRSOLECOMPENSA710N, � COmmefCial -
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SAIE(SEC.70�d,BUSI� J
� NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NO7 APPLV TO AN OWNER OF �
PROPERTV WHO BUILDS OR IMPqOVES THEREON,AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR
� THROUGH HIS OR NER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
w OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
0 TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NO7 BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE).
�_ ❑I,ASOWNEROF7HEPROPERTV,AMEXCLUSIVELVCONTRACTINGWITHLICENSEDCANTRAC70RS
TO CANSTRUCT THE PRQIECT(SEC.7a4,BUSINE55 AND PROFESSIONS CODE:7HE CON7RACTORS LI� VelUetiOfl ADJ.AREA /'�
W CENSEUWDOESNOTAPPLYTOANONRJEfiOFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND /
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Y TORS LICENSE LAW.). ,+'�
� O I AM EXEMPT UNDER SFC. B.8 P.C.FOR THIS REASON Q �
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNDER PENALTV OF GERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d 9(COMMENCINC�WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CADE,AND Z
X AIY IICENSE IS IN FULL FORCE AND EFFEC7. 1�
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WORKERS'COMPENSATION DECLARATION Q .
� I HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z .
Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _
Q CAMPENSATION,AS PROVIDED BY SEC7ION a7oo OF THE LABOR CODE.FOR THE PERFORMANCE 'U ,
OFTHE WORN FOR WHICH THIS PERA1171S ISSUED. �
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� I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION { '7 O ,
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ' �7- ( �
ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIEH AND POLICV NUMBER ARE: CONSTRUCTION /�
� CARRIER Stat e f'vLnDr PLAN REVIEW
Z POLICY NUMBER I3� T��'`7 '6 I ELECTRIC
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� (iHI55ECi10NNEmNO7BE00AWtTEDOFTHEPERMITISFORONEFNIDREDDq1AfLS(5700)ORLESS). PLUMBING
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Z I CER7IFV THAT IN 7HE PERfORMANCE OF THE WORK FOH WHICH THIS PERMIT I ED,I MECHANICAL �
(.'} SHALL NOT EMPLOY ANV PERSON IN ANY MANNER 50 AS TO BECAME SU C T �'
N WORKERS'COMPENSATIONLAWS I ,ANDAGH THATIF HOUL BE E INSPECTIONFEE
� SU&IECT TO THE WORKERS'COAIPENSATION PFO SIONS O SE TIO 37o00F THE BOR
� CO E,ISHALLFORTHWITHCOMPLYWIT THOSEP O ISIO . ISSUANCE o �nni I
p DATE: ��I�I APPLICANT: SMIP I ��
� ENERGY P/C r'�s r I
J WARNING:FAILURE TO SECURE WORKERS'C A710N COVEFiAGE IS UNLAWFUL,AND SHALL E �� _ �
� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSA D ENERGYPERMIT "`- �-
DOLLARS(f100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR N
� SECTION 37080FTHE LABOR CODE,INTEREST,ANDATTORNEV'S FEES. RETENTION FEE: �
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV 7HAT THERE IS ACONSTRUCTION LENDING AGENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.3097,CIV.C.�.
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� LENDER'S NAME
H LENDER'SADDRESS
� TOTAL FEES � 7 7
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE MFORMATION IS CORRECT.
w I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUIL�ING
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� CONSTRUCTION,AND HEREBV AUTHOHIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE�MEN710NED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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� SIGN TUREOF E . DATE
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SLAB GRADE FIREPLAC��FdUNbATICON i� ' " � i____ �
TEMP POWER I FIREPLACE BONQ BEAM
WATER SERVICE � MID HT. BOND BEAM � � __
ROOF SHEATHING 8 F-i'. BONp.BEAM � ' ' i • � __
FRAMING/VENTILIATION FIPIAL BOND_BEAM _ � ____ ____
ROOF COVER PRE-GRADING
ROUGH HE,4TING BENCHING
ROUGH ELECTRIC ROUGH GRADING __ __
ROUGH PLUiV161NG FINISH GRADING
SHOWER/TUB TEST � POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL
CEILIiVG IN�ULATION OFF SITE IMPS.
DRYWAL�tJAI�ING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TA(VK � �, LANDSCAPE/IRRIG.
SEEP PIT/�.L. • ON SITE IMPS.
GAS AIR TEST FINAL ZOf�ING
FINAL CONST. FIRE DEPT. FIiVAL
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FINAL ELECTRIC DEV. FEES PAID
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