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��� CITY OF DIAMOND BAR �
II DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVIC .-
21660 E.Copley Drive Suite 190
(909)860-3195 Fu(909)861-3117 � �RESS
������'� BUILDING PERMIT APPLICATION _ `— FIRMLY I
o� JOBSITE� ^ `.,G��OGL DATE C T�TC/� NUMB R�_ #/C
ADDRES �7S� Ll���. � �
$ ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER
� ADD ZONING SETBACKS
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� DESIGNER NO.DWEL. NO. NO.
a ADDRESS UNITS STORIES BEDROOMS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBY AFFIRLI UNDER PENALTY OF PE0.IURV THAT I AM EXEMPT FROM 7HE CONTMCTORS LI� � Garege/Carport
W CENSEUWFORTHEFOLLOWINOREASON(SEC.7031.SBUSINESSAN�PROFESSIONSCODE:ANYCI7YOR
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� TURE.PRIOR TO 1T9 ISSUANCE.AL50 REWIPES THE�APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED w
STATEMENT THA7 HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF T1E CONTMCTORS LI�
� CENSE LAW(CHAPTER i(COMMENCINO WI7H SECTpN 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooUSpa
FESSqNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED EXEMP�
TION.AHYVqLATqNOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTY OF NOT MORE 1HAN FIVE HUNDRED DOlURS(f5o0).):
� ❑I,ASOMMEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSA710N, � CORIrtIBfC181 �
MALL DO THE WORK,AND THE STRUCiURE IS NOT IMENDED OR OFFERED fOR SALE(SEC.701�,BUSI� J
� � NESS AND VROFESSIONS CODE:THE CANTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF �
PROPERTV N?10 BUIlD50R IMPROVES THEREON,MID WHO DOES SUCH WORN HIMSELF OR HERSELF OR
� 7HROUGH HIS OR MER OWN ELIPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
� OFFEREDWRSAIEIF,HOWEVERTMEBUILDIN00RIMPROVEMEHTISSOLDWITHINONEYEAROFCAMPLE-
Z �TION,THE ONMERAUILDEH WILL HAVE TIE BURDEN OF PROVIN�THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR 7HE PURPOSE OF SALEJ.
w ❑I,ASOWNEROFTHEPROPEHfY,AMEI(CLUSIVELYCONTMCTINOWfTHLICENSEDCONTMCTORS
Q TO CONSTRUCT THE PR0.IECT(SEC.7041,BUSINESS AND PROFESSIONS CODE:THE CON7RACTORS LI� V81U8110f1 ADJ.AREA
W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWFIOBUILDSORIMPROVESTHEREON,AND
� NRIOCOHTMCTSFOHSUCHPR0.IECTSWITiACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE
Y TORS LJCENSE UW.).
� ❑1 AM E%EAIVT UNDER SEC. B.8 P.C.FOR THIS REASON Q � �
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OATE ONMER V
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNOER PENALTV OF PE0.IURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �}�
� Y(COMMENCINO WITH SECTION 7oa0)OF DIVISION 7 OF 7HE BUSINESS AND PROFESSIONS CADE,AND Z � l U �
��� MY UCENSE IS IN LL FOHCE AND EFFECL � i/r�,y}�
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r� WORKERS'COMPENSATION DECLARATION Q
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N I HEREBY AFFIRM UNDER PENALTY OF PEFLIURV ONE OF THE FOLIAWING DECURATIONS:
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0 I HAVE AND M/ILL MAINTAIN A CEfiTIFICATE OF CANSENT 70 SELF-INSURE FOR WORKERS' 2
� OOIAPENSATION,AS PROVI�EO BY SECTION 370o OF THE LABOR CODE.FOR THE PERFORMANCE W
OF THE WONN FOR VAiICH 7HI5 PERMIT IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE,AS REOUIRED BV SEC710N �
Q 370a OF THE UBOR OODE,FOF THE PERFOHMANCE OF THE WORK f-0R WHICH THIS PERMIT IS
ISSUED.MY WORKERS'COMPENSATION INSURANCE CAFiRIER AND POLICV NUMBER ARE: CONSTRUCTION
jc,�qpiEq PLAN REVIEW /
� PaICYNUMBER ELECTRIC A
� (I}SSSECiqNNE�NOTBE001.pLEfIDOFhEPERMTSFi�RONEFIU�(iED iro)oa�ss�. PLUMBING
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Z I CEHTIFY THAT IN h1E PERFORMANCE OF THE WO OR WHIC PERMIT ISSUED,I MECHANICAL
�} SHALL NOT EAIPLOY ANV 7ERSON IN ANY MAN 50 TO B OME U TO THE i
N WORKERS'COMPENSA710N UWS OF CI�LIF IA,AN AGRE SHOULD BECOME INSPECTION FEE �
S SU&IECT TO THE WORNERS'COMPENSATI PROVI NS ION a7oo OF THE L1BOR �1.(�,
E SH FORTHWITHCAMPLVWI7H SE OVISIO . ISSUANCE O�l
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p DATE: `� �---APPLICANT: ,
W ENERGY P/C
J WARNINO:FAILURE TO SECURE WORKERS'CAMPENSATION CAVEitAGE IS U W L,M1D SHALL BE -
� SUBJECTANEMPLOVEHTOCRIMINALPENALTIESANDCIVILFINESUPTOON HUN EDhIOUSAND ENERGYPERMIT
DOLLARS(floo,o00),IN ADDITION TO THE COST OF COMPENSATION,DM1AG S AS P OVIDED FOR IN
J SECTION 37oa OF TIE LABOR CODE.IN7EREST,AND ATTORNEV'S FEES. RETENTION FEE:
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a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT TMERE IS A CONSTRUCTION LENDING AGENCY
FOR 7NE PERFORM/�NCE OF 7HE WORK FOR WHICH THIS 7ERMIT IS ISSUED(SEC.3a�7,CIV.C.).
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� LENDER'S NAME
F� LENDER'SADORESS . �f
w I CER7IFV THAT I HAVE READ THIS APPLICA710N AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �p�J O
� I AGREE 70 COMPLV WITH ALL CRV PND GOUNTV ORDINANCES ANO STATE UWS RELATING 70 BUILDING
� CONSTRUCT AND HER AUTHORIZE REPRESENTATIVES OF 7HI5 COUNTY TO EMER UPON THE
Z ABOVEME I 10 ED PR R FOR INSPEC7�oses. COMMENTS �
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� SIG OF EE DATE
= RECPT.NO. PAID BY � VALIDATION
~ WHITE—Depertment Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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ROOF SHEATHING � '' 1 �� �` �' �����'8 FT. BOND•BEAM � '
FRAMINGNENTILIATION . ` � ' !,�', + `j-. �� '^ '• ��INAL BOND BEAM �
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ROUGH E�ECTRIC ____� � ., OU,G��GRADING
ROUGH PLUMBING ' ' ' •, 1N1 �H,"RADING �
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CEILING I�lSULATION OFF SITE IMPS.
DRYWAL.L NAILING DEDtG�TIONS � : •u. �:.-•�. -�----^---
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