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_f� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES `-
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117 PRE$$
��`��' BUILDING PERNIIT APPLICATION FIRMLY
� JOBSITE S �� APPLICATIO�I PERMIT P/C
o ADDRESS�� � � UQ 1'I' DATE � � 4� NUMBER�� #
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v� DESCRIPTION S�.Ff. FACTOR PSF ADJ.AREANALUATION
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� TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES 7HE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED W
STATEMENT THAT HE OR SHE IS LJCENSED PUfiSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSp2
FESSIONSCODE)ORTHATHEORSHEISEI(EMPTTHEREFROMANDTMEBASISFORTHEALLEGEDEXEMP- (�
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� ACIVIL VENALTY OF NOT MORE hiM!FNE HUNDRED DOLURS(i5o0).�:
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MIILL DO THE WORI(,AND THE STRUCNRE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.70M,BU51• J
N NESS AND PiqFESSIONS CODE:7HE CANTMC70H5 LICENSE LAW DOES NO7 APPLY 70 AN OWNER OF �
PROPEHfY NM1IO BUILDS OR IMPROVES 7HEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
CC THRd/0H HIS OR HER OWN EM7LOYEES.PROVIDED THAT SUCH IMPROVEMENTS ARE NOT IN7ENDED OR m
� OFFEREDFORSALEIF,HOWEVERINEBUILDINGORIMPROVEMENTISSOLDWRHINONEVEAROFCOMPLE-
Z �'TION,THE OMMER�UILDER MALL HAVE THE BURDEN OF VROVINO THAT HE OR SHE DID NOT BUILD OR
� IMVROVE f-0R THE PURPOSE OF SALEJ.
w ❑I,ASOVMEROF7HEPROPEHTY,AAIE%CIUSIVEIYCOMMCTINOWfTHLICENSEDCONTMCTORS
� TO CONSTRUCT THE PR0.IECT(SEC.7oH,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS LI- V81U8fI0f1 ADJ.AREA
W CENSEUIWDOESNOTAPPIYTOANOMMEROFAVRbPERTVWHOBUILDSORIMPROVE57HEHEON,AND
� WFiOCONTRACTSFORSUCHPR0.IECTSWI7HACONTRACTOR(5)LICENSEDPURSUAHTTO7HECONTRAG pUANTITY DESCRIPTION FEE �
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Q O I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� I HEHEBYAFFIRN UNDER PENALTV OF PERIURY THAT I AM LICENSED UNDEH PROVISIONS OF CHAPTER � L �'�'
� 0(ODIAMENC�NO WITH SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE.AND Z r � 1..�
X W LICENSE IS IN FU ORCE AND EFFECT. `_ U
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V DATE � ^ Z 9 � L� CONTRACTOR •V� OYI a a
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� WORKERS'COMPENSATION DECLARATION Q
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� 1 HEREBV AFFIRM UNDER PENAL7Y OF PERIURY ONE OF THE FOILOWING DECURATIONS:
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O _I HAVE AND WILL MAINTAIN A CEqTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' 2 �
Z COMPENSATION,ASPROVIDEDBYSECTION97000FTMElA80RCODE,FOflTHEPERFORMANCE U
Q OF THE WORK FOR WHICFI THIS PERMIT IS ISSUED. �
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W _I HAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SEC710N
Q 37000F THE IABOR CODE.FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
�.SSUED.MY W�O RS'COLMPENSATIOTNJt+SUR/W�C�1.cARRIER M!D POLICV NUMBER ARE: CONSTRUCTION
j . cawqtER � vT[.�'r� rU n Ci PLAN REVIEW
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(h4SSECIIONNEIDNOTBE00MPLEfmOF7HEPEiARfISFORONEHUN%iEDDOLtAfi5K10010i7LESSl PLUMBING y-: •
Z I CERTIFY iHAT IN 7HE PERFORMANCE OF THE WOHK fOP WHICH THIS PERMIT IS ISSUED,I MECHANICAL �� ! r •' \ � �
(;J SHALL NOT EMPLOY ANY PERSON IN ANV MANNER 50 AS TO BECAME SUBJECT TO THE J �
� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREE7HATIFISHOULDBECOME INSPECTIONFEE �j�` J.S
S SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SEC710N 3700 OF 7HE LABOR n � (�
CADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVI `5.�( n ISSUANCE �/f�� � �I I��
p DATE: ^�7 � �PPLICANT:�ITI� ��/'��'l.�C�V�C �SMIP � •••. -.- ,
� ENERGY P/C � --.-.--
J WMNINO:FAILURE TO SECURE VlORKERS'CAMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE - - �„
� SU&IECT AN EMPLOYER TO CRIMINAL PENAL71E5 AND CIVIL FINES UP 700NE HUNDHED THOUSAND ENERGY PERMIT ���' `'
DOLURS(f70o,000�.IN ADDITION TO THE CO57 OF COMPENSATION,DAMAGES AS PROVIDED FOR IN I
� SECTION 37oB OF THE LABOR CODE.IN7ERE5T,AND ATTORNEY'S FEES. � RETENTION FEE: I c
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THEPE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WOHK FOR WHICFI7HIS PERMIT IS ISSUED(SEC.3007,CIV.C.). .
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� LENDER'SNAME
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� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFOFMATpN IS CORRECT. TOTAL FE ES G/ �, �� �
w I AGPEE TO COMPLY WITH AL�CRV M1D COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING �
� CONSTRUCTION,AND EREBV AU7}10RIZE RE7RESENTATIVES OF 7HI5 COUNTV TO ENTER UPON 7HE �
ZABOVE-MEN710NE R PERTV FOR INSPEC710N PURPOSES. COMMENTS � '
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� RECPT.NO. �J PAID BY � VALIDATION
WHITE-0epertment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Copy
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ROOF SHEATHING 8 FT. BOND BEAM
FRAMINGNENTILIATION FINAL BOND BEA(vl
ROOF COVF_R PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUfVIBING FINISH �RADIiVG
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