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CTTY OF DIAMOND BAR
------���-- DEPARTMENT OF COIvIIvIUNTI'Y&DEVELOPI�NT SERVICES
� 21825 E.Copley Drive
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":���'`~ BUILDING PERMIT APPLICATION FIRMLY
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o ADDRESS � l� VJ - DATE �
ISSUE TYPE OCC
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� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
� OWNER•BUILDER DECLARATION SFR/ADD/REM
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0 I HEREB�AFFlRM UNDER PENALTI OF PERNRV THAT I AM E%EMPT FROM THE CONTRACTORS LI- G8fA9B/CBfPOf1
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wTURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIdNED w
� STATEMEM THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF iHE COF7TMCTORS LI- LL POOI/SP8
� CENSE LAW(C7iAPTER D(CAMMENCINO WITH SECTION 700a)OF DIVISION 3 OF THE BUSINESS AND PRO�
^ FESSpNSCO�E)OFh7ATHEORSHEISE%EMPTTHEREfROMANDTNE8A515FORTHEALIEGEDEXEMP�
� TION.ANV VIOLATION OF SECTION 7031.5 BV M7Y�PPLICANT FOR A VERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
� A CML PENALTV OF NOT MORE THAN FNE HUNDRED�OLLARS(S6ao�.):
O �I,AS OWNEROFTHE PROPERTV.OF MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. � CpmmBICfBI
Z WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70�a,BU51- J
� NESS MJD PROFESSIONS CODE:THE CONTFACTOF75 LICENSE LAW DOES NOT APPLV TO AN OWNEA OF �
PROPERTYWFiOBU1LDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFOFHERSELFOR m
� TMROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUq11MPROVEMEMS ARE NOT INTENDED OH
W OFFEREDFORSALE.IF,HOWEVEflTHEBUILDINOORIMPROVEMFMI550lDN�THINONEVEAROFCOMPLE-
� TION,THE OWNER-BUILAER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DID NOT BUILp OR
Z IAIPROVE FOR THE PURPOSE OF SALE).
W ❑I,ASOWNEROFTHEPROPERTY,MIEI(CWSNELYCONTHACTINGWITHUCENSE�COHfRACTORS � OO� ��
� TO CONSTRUCT THE PR0.IECT(SEC.7oM,BUSINE55 AND PROFESSIONS CODE:THE CAMRACTORS U- V8I118fIOf1 Aa.AREA
W CENSE LAW DOES NOT MPLV TO AN OMMER OFA PROPERTV WHO BUILDS OR IMPROVES THEREON,AND
� WHOCONTMCTSF-0RSUCHPROJECTSWITHACAN�RACTOF($)LICENSEDPURSUANTTOTF7ECONTRAC� QUANTITY DESCFIPTION FEE
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� O I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON � �
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� � LICENSED CONTRACTORS DECLARATION �
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I HEREBV AFFIRM UNDER PENALTV OF PERIURV 7//AT I AM LICENSED UNDER PROVISIONS OF CHAPTER � , {A
p_, B(COMMENCINO WITH SECTION 7oao)OF DIVISION 3 OF THE BUSINE55 AND PROFESSIONS CADE,ANO Z � �
X MV UCENSE IS IN FULL FORCE AN�EFFECT. m J
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� UCENSECLASS �/ UC.NO. �S��J �
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� WORKERS'COMPENSATION DECLARATION J
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� I HEREBY AFFIRM UNDER PENALTY OF PERJURV ONE OF THE FOLLOW WG DECLARATIONS:
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� I HAVE AND WILL IM�NT/,IN A CERTIFICATE OF CONSENT TO SELF-INSUFE FOR KORKERS' 2
� COMPENSAf10N,AS PROVIDEO BV SECTION 37oa OF TME LABOR CODE.FOR THE PERFORMANCE w
OF T1E WOPK FOR WHICH TMIS PERMIT IS ISSUED. �
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w �I HAVE AN�N�ILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION 1
Q 370o OF THE LABOR COOE,FOR THE PERFORMANCE OF iHE WORK FOR WHICH THIS PERMIT IS `�a��O
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIEF AND POLICY NUMBERARE: CONSTRUCTION t
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� CAARIER ST�Q ��N — PLAN REVIEW �/ �
� POI.ICVNIMRFR /_�I9�I � ELECTRIC /�
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Q (rt115sEcnoNNE�rarBEmdRErEooFnfvEwxrSraiaNEFl1�ORE000uJlRs(Ltroloal£SSl PLUMBING �!•s0
w I CERTIFV THAT IN THE OERFORMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUED,1 MECHANICAL � � YT- �� J�,TO
Z d• ��—•.� � 1 1 J �
(•} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SOAS TO BECAME SU&IECT TOTHE �•..�.f ,
N WOqKERS'COMPENSATION LAWS OF CALIFORNIq AND AGREE THAT IF 1 SHWLD BECOME INSPECTION FEE � �+ ;
� SU&IECT TO hIE WORKEflS'CAA/7ENSATION PROVISIONS OF SECTqN 3700 OF THE IABOR � I l�pl 1 '1 �n n� � ,' -
CODE.I SHALL FORTHWIiH COMPLV WITH THOSE PROVISIONS. ISSUANCE /O�`
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p DATE:�_g d �- APPLICANT: � "r ` I . I
� � ENERGY P/C I
WAANINO:FAILURE TO SECURE WORKERS'CAM7ENSATION CAVERAO S UNLAWFVL.AND SNALL BE ���
�y SUBJECTAN EMPLOVER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT M=--`�--� � _ _ '
DOILARS(S10o.o00),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PRO V I D E D F O R I N ----._____�
J SECTION 3708 OF THE LABOR CODE,INTEREST,M1D ATfORNEV'S FEES. RETENTION FEE:
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w CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERJUFV THAT THERE I$A CONSTRUCTION LENOMG AGENCV
� �- FOR 1HE PERFORMANCE OF TME WORN FOA WHICN THIS PERMIT IS ISSUED(SEC.7087,CIV.CJ.
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� LENDER'S NM1E
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wI CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT. TOTAL FE ES�ya/� � O� � � � '7. �
� I AGREE TO COMPLV WITH ALL ClTY AND CWNTY ORDINPNCES AND STATE LAWS fiELATING TO BUILDING �� � I �
� GONSTRUCTION,AND HEREBV AUTFpRRE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z A90VE�MENTIONEO PR07ERTY FOR INSPECTION PURPOSES. COMMENTS
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� � SIGNATUREOFPER EE oArE RECP7.N0. PAiDBY VALIDATION
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�' � WHITE--Department Copy.YELLOW—Finance Capy.PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanCs Copy
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SET BACK - �LOOR JOIST
FTGS/FORMSlSTEEL �2'�,-.pZl _ FHA REt�MTS
ELECTRIC GR'bUND 'L2a'L �,�.-� UNDER FLOOR DUCT ~
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GROUND PLUP+/iBING 'Z.'�� � UNDER FLOOR CU�IDUIT
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIFtEPLACE BOND BEAM �
WATER SERVICE � MID HT. BaND BEAM
ROOF SHEATHING 8 FT. BONO BEAM
FRAMIfVGNENTILIATION FINAL BOND BERM �
ROOF COVER PRE-GRADING �
ROUGH HEATING BENCHlNG
ROUGH ELECTRiC (Z,1.-D ROUGH GRADING
RQUGH PLUIVISING (�,Z�_�_ FINISH uRADING
SHOWER/TUB TEST POOL ELECTRIC (�Z,'�-�Z.
EXT. LATH/SIDING POOL FENClNG 3%��y,
WALL INSULATIOfV POOL FINAL 3�,�dc�7 .�!f/
CEILING IN�ULATION OFF SITE IMPS.
DRYWA�L NAILfNG DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK IANDSCAPE/IRRIG.
SEEP PIT/LL. ON SITE IMPS.
GAS AIR TEST �_�,2-p2 FINAL ZONING
FlNAL CONST. �'�'�z . ' FIRE DEPT. FINAL
FINAL HEATING HEAL7H DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBING � ENERGY
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