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CTTY OF DIAMOND BAR � I
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21825 E.Copley Drive PRESS
„' (909)860-3195 Fax(909)861-3117 i
``:.»w%'w BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE L Q �/ ,/ APPLICATION r PERMIT /� P/C
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$ ISSUE TYPE OCC
APN LOT TRACT DATE 3��� z� CONST. GROUP
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DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATION SFR/ADD/REM
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W1URE,PRIOR TO ITS ISSUANCE.�LSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIONED W
� STATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � pOOUS
� CENSE UW(CHAPTER B(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND Pq0- � Pa
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� A CML PEIULTY OF NOT MORE TNAN FIVE HUNDRED DOLURS(f5ao).):
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Z WILL DO THE WOR1C.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7oa�,BU51� J
N NESS AND VROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNEA OF �
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� TION,THE OWNER�BUILDER VJILL HAVE TME BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
Z IMPROVEFOR7HEPURPOSEOFSALE).
_ ❑1,AS OWNEROF THE PROPEFTV.Ml EXCLUSIVEIY CANTRAC7ING WITH LICENSED CONTRAC70R5
� TO CANSTRUCT iHE PROJECT(SEC.70U,BUSINESS AND PROFESSIONS C�DE:THE CONTRACTORS U� V9I110�IOf1 ADJ.AREA
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� O��EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON �
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� LICENSED CONTRACTORS DECLARATION �
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I HEREBV AFFIRM UNDEF PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAGTER �
� Y(COMMENLWOWIiHSECTION7000�OFDIVI510N70FTHEBUSINESSANDPROFES510NSCODE,AND Z
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� WORKERS'COMPENSA710N DECLARATION Q
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV ONE OF THE fOLLOWING DECLARATIONS:
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� _I HAVE AND N�ILL MAINTAIN A CERTIFICATE OF CANSENT TO SELF-INSURE FOR NORKERS' S
Q CAMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE.FOF THE PERFORMMlCE W
OF TNE WORK FOR WHICM THIS PENM�T IS ISSUED. �
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w �IHAVEANDWILLbUINTAWWORKERS'COMPENSATIONINSUMNCE.ASREOUIREDBVSECTION /�/ -
Q 3700 OF 7HE LABOR CODE,FOR 7HE PEHFORMANCE OF THE WORI(FOR WHICH THIS PERMIT IS
ISSUED.MV WORKEFS'COMPENSATION INSURANCE CARRIER AND POUCV NUMBERARE: CONSTRUCTION
� CARRIER PLAN REVIEW
� POLICV NUM6ER ELECTRIC
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w MECHANICAL
Z I CEFiTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS�ED.I
� SHALLNOT EMPLOV ANV PERSON IN ANV MANNER SOAS TO BECAME SUBJECT TOTHE INSPECTION FEE
� WORKERS'COMPENSATION 1AW50F CALIFORNIA,AND AGREE THAT IF I SHOULD BEGOME ^ ' „^
� SU&IECT TO THE WORKERS'COMPENSATION PHOV1510NS OF SECTION 37o00F THE I.ABOFl ISSUANCE L �lV
� CODE.I SHALL FORTHV/ITH COMPLV WITH THOSE VqOVIS10NS. �
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p DATE:v ��O�P%.ICANT: 7 .
w �ENERGY P/C
J WARNING FAfLURE TO SECURE WORKERS'COMPENSATION COV GE�S UNLAWFUL AND SNALL BE
�—y SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED T}KKISAND ENERGY PERMIT
OOLLARS(f100.000).IN AODIiION TO THE COST Of COMPENSATqN,DAMAGES AS PROVIDED FOR IN •OO
J SECTION 370e OF 1HE LABOR GODE,iNTEREST,�ND ATTORNE'fS FEES. RETENTION FEE:
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W CONSTRUCTION LENDING AGENCY pRE-ALT FEE:
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CL I HEREBV AFFIRM UNDEF PENALTV OF PERIURV THAT THERE IS A CANSTRUCTION LENOING AGENCY
d FOR THE PEHFORMANCE OF h1E WONK FOR WHICH THIS PEN.��T�S ISSUED(SEC.9091,CIV.C.). '
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� LENDEAS NAME C'� �� –�� �—�
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� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS COPRECT. TOTAL FE ES,r /� r'`� � � .` J
W I AGFEE TO CAMPLV WITH ALL CITV AND CAUNTY ORDINANCES AND STATE LAWS HELATING TO BUILDING � IVIAR I� " ' ^r�
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUN1l'TO ENTER U�ON THE 41 ��
� ABOYE�MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS c
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� sicNnT OF PE Ee , onrE RECPT.NO.� PAID BY VALIDATION
� WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLAENFO�File Copy,GFiEEN—Applicant's Copy
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SLAB GRAQE FIREPLACE FOUNDAl'ION �
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WATER SERVICE MID HT. BOND BEAM
ROOF SFiEAfHit�lG ��Z ��- 8 F7. BOND BE�iVf�< .� _
FRAMINGNENTILIATION FIPIAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HE,4TltVG BEPVCHING
ROUGH ELECTRIC ROUGH GRADING�
ROUGH PLUIVIBING FINISH uRADING
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EX7. LATH/SIDING POOL FENCING
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CEILING INSULATi�N OFF SITE IMPS.
DRYWA�L�lAILING DEDICATIONS '
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SEEP PIT/L.l.. ' ON SITE iMPS.
.GAS AIR TEST FINAL Z�NING �
FINAL CONST. , �=lRE DEPT. FINA!
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