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CITY 4F DIAMOND BAF�
--- "�'�`— DEPARTMENT OF COMMUNITY&DEVBLOPMENT SER.VICES
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(4Q4)864-3195 Fs�c(904}861-3117 PRESS
��riM'�� BUILDING PERMIT APPT.ICATION � ��}�1(`� ,�� FIRML.Y
� JOBSITE �'"� ,�.���,y.,, J�1 H �.. APPLICATION f��� �� !�k NUMBER ����Yt�, PIGC'�� { /^.
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APN �OT I D TRACT �,� DATE _GbNST_ GpOUp
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� ADDRESS�. � ZONING SETBACKS
� � FRONT RW ._ ❑
CITY �_ ZIP TEL�
APFLIGANT _ "���T TEL. REAR ❑
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t� ARCFUENGt � " �{, �_ .
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� CENSELAWFOitTHEFOILOWIN(#REAS�ONf5EC.70.31.50USINES$ANDpPOFES570NSCOCIE:ANYCittoR (n �
COUN7V WH1CH REtN11RESA PfRMIT 70 CONSTRU(:T.AL7ER.IMPROVE.dEMOUSN,OR REPAIR ANY STFUC�
NR£,PRlQii TQ RS 7SSUMiCE.A156 REIX14RE5 THE Ai'PLICAN7 FOR SUCH PERbttT�Q FILE A SiGNEtJ � PaliOIDBCk °�..� i�
STATEMENT TMAT HE OR SHE IS LICENSED PURSUANT TO lllE PROVISIONS OF THE CON7MC70R5 ll•
� CENSE tAW(CHA!'iEft Y(COMMENGNO WITN SEC710N 7G00�OF DIVISN?N 9 OF THE BUSINESS AND PRq- u' POqUSpB
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VALL C10 THE WORK,M1D THE STRUCTUAE IS NOT INTENpED QR OFF�RED FOF SALE(SEC.7n44,BU51� J
� NESS AM1 PpOFESSiONfi COOE:THE CANTHAC7�i3 t10ENSE tAW D(7E5 NOT APPIY TO AN OWNEA QF .
PROPEFiTYWF10BUILDSORIMPROVESTHEREON.ANDWNODOESSUCNWOflKHIMSEtFpRHERSEtFOR � J
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� IMPRt}YE fOA THE PURPOSE OK 51LL.E1.
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� DATE OWNER F"' �
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I HEflEBY AKFIPAI UfJDER PENALTY OF PER.iURY TFipT tAM LICENSED UNOER PROVISIONS OF CHAPTER � '['^ ✓ rr
a i(COMMENCIN(a WiTH SBCTION 70007 OF DIVISION 9 OF THF.OUSINE5S AND PROFESSIONS CO�[,ANO Z 7 ��
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� �HAVEANDWILlMAM1TAMACERTIFICATEOFCONSENTTO5E1FiNSUREFORiYf3Ri(ERS' � r � � l�
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ZW I CEATih'V THAT IN THE PFRFORMANCE OF TME WOAN FOR WNICH TFi15 PERMIT IS ISSUED.I MECHANICAL t t" �
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(,r} SHAIt N4T EMPIOY MIY FEflSON IN ANY MANN6f2 SO AS'Q BECOh4E SUB.t£GT T6 THE ���
� KGRKENS'COMPENSATION LAWS 4F CAUFORNIA AN�AGREE THRT IF I SHOULD BECOME FNSPECTION FEE ,
� SU&IECT TO TNE VIDRNERi'COMPENSATION PROVISN?NS OK SECTION 37C10 OF THE LABOR � .-
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'J WMNlNG:fNWRE TO SECUHE V✓oHKERS COMPENSA710N COVERAGE�5 UNLAWFUL,AND SHAIL BE ENERGY P!C f u';,��—�� � ��•
J SUBJEGTAN EMPIOYER T6 CRiMMAt PENALT4E5 AND GiVil FWES UP TQ fltiE HUNDREO TiiOUSANQ
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S SEGTl6N81QdQFTHEU!&ORCO�E,INTEftEST,ANDATTQRNEY'SFEES. � __ ,.-.FJt,I�_
FIETENTtON FEE: __�.�� +�.�_r,�
d CONSTRUCTION LENDING AGENGY PRE-ALT FEE: �
� I HEREBV AFFIRM UNDER PENPLTY OF PERJURY THAT TH'eRE IS A C.ONSTRUCTION LENOING AGENCV `—� ��µ�
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� IENDER'S NAME __ 1 i
F- LEN�ER'S ADDRE55_ ...,—„.
WIGERTIFYTHATIHAV�qEADTHISAPPLICAT1oNANDSTATETHATTHEABOVEINFpRMAT10NI5CARRECT. TV�AL�CEJ ,� '�I����.
� 1 AGREE70 GOMPLY WITN AU.CITY AND CAUNTY ORDINANCES MlP STAT6 LAWS RELATING TO BUILpING Oi�l 1
� CONSTRVCiION,ANDriEREBYAUTHORi2ER£PRESENTAT3V6S0%iHISCOt/NTYTOENTEFiUPptiTHE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION I-�
� PERMIT
#/Co�
DATE NUMBER=-1
ISSUE TYPE S- 1 �x-0 OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR ^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SC. FT FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM Z IJ ,
Garage/Carport
W Patio/Deck
W
LL Pool/Spa
0
Z Re-Roof
Commercial
1J
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
Q yr
U
/•
W
W GG/
mvi -
Z 5 Ib' 17 6>
F5 15;_ tl�� 5- 1110
= ef
/S
z JI
y 0
J�
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CONSTRUCTION 3(p
(o
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL L-
INSPECTION FEE
ISSUANCE 1 0 V. I�I V
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: MAY_. -M„-
PRE-ALT FEE: t
I
TOTAL FEES ��' ;t(JL,
COMMENTS
RECPT. N0. PAID BY VALIDATION
JOBSITE
ADDRESS
APN LOT I D TRACT 2 1p�7
OWNER
ADDRESS
CITY X V Vi Gri- ZIP 6 TEEM
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY P
ARCH/ENG/
r
110'��o
t
DESIGNER
r
ADDRESS
CITY ZIP c TEL. r
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER. IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE.
IKON.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE IS IN FULL FC AND EFFECT.
LICENSE C S ry LIC N0.
DATE---'!%CONTRACTOR
X
COMPENSATION DECLARATION
WORKERS
1 HEREB AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE i ABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
INS IRANCE CA/PIIER AND POLICY NUMBER ARE/::
ISSUED. MY KEPT COIM NSATIIOON
• 1.-+/
v
CHARIER\�v
PJ.1LLCy NUM�BER�- ._
T
gNNEOO T E OAN EFED OFTHE PERAtt IS FOP ONE F&PDRED C.LARS(E100)OR LESS).
SSC
I4S
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
S
NS
COPE.I SHALL FORTHWITH COMPLY WITH THHOSEPROVI
IO
r
IS
+
S.
y��
/ ! /I11VI111YY
/
APPLICANT:
DATE:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
_ RMANCE OFTHE WORK=0 H THIS PERMIT ISSUED (SE9V. C
FOR THE PERFO
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
k
C PERMITTEE NAME(PRINT)
_ _^'0�
7
0 SIGNA OF PERMITTEE DATE
C
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy