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/ CITY OF DIAMOND BAR �XPIF��[�
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21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
��'%»��'" BUILDING PERMIT APPLICATION FIR Y
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APN LOT TRACT DATE �V �� CONST. GROUP
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I HEREBV AFFIRIA UNDER PENALTY OF PERJURV THAT I AM E%EMPT FROM 7HE CONTRACTORS LI� G8f8QB/CBfpOR
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w TURE.PRIOR TO ITS ISSUANCE.ALSO RE�UIfiES THE APPLICANT FOR SUCH PERMI7 TO FILE A SIGNED w
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RAC70R5 LI- �
� CENSE LAW(CHAPTER e(CAMMENCING WI7H SEC710N 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- POOUSPe
FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (rJ
� TION.ANVVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNORED DOLLARS(5500).):
ZOI,ASOWNEROFTHEPROPER7Y,ORMYEMPLOVEESWITHWAGESAS7HEIRSOLECOMPENSATION, 0 COmrtlOfCie1 -
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7od�,BU51- J
� NESS ANO PROFESSIONS CADE:THE CANTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNEfi OF � �
PROPERTY VhiO BUILOS OR IMPROVES THEREON,PND WHO DOES SUCH WOHK HIMSELF OR HERSELF OR
[C THFiOUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTEN�ED OR m
0 OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMEN7ISSOLDWITHINONEVEAROFCOMPLE-
Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING 7HA7 HE OR SHE DID NOT BUILD OR
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w ❑I,ASOWNEROFTHEPROPERTV.AME%CLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS
� TO CANSTRUCT THE PRQIECT(SEC.70�6,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI� V8IU8�lOf1 ' ADJ.AREA
W CENSEU�WDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND
� WHOCONTRACTSFORSUCHPPQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECANTfiAC- QUANTITY DESCRIPTION FEE
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O O I AM EXEMPT UNDER SEC. 8.8 P.C.FOR THIS REASON Q
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNDER PENPLTV OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F 7HE BUSINESS AND PROFESSIONS CODE,AND Z
`X MV LICENSE IS IN FULL FORCE AND EFFEC7, m
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LICENSE C S LIC.NO. �
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� WORKERS'COMPENSATION DECLARATION Q
� 1 HEHEBV AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECLARATIONS: Z
� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _
Z CAMPENSA710N.AS PROVIDED BV SECTION 370o OF 7HE LABOR CODE.FOH THE PERFORMANCE U
¢ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WOflKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION � ^l
Q 3700 OF THE LABOR CODE,FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PEfiMIT IS A� ��
0 ISSUED.MY WORK 'COMPENS ION INS A CARRIER D POLICV NUMBER ARE: CONSTRUCTION I�J V � ��
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� CARRIER PLAN REVIEW
Z POLICY NUMBER � ELECTRIC
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Z 1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(.r} SHALL NOT EMPLOY ANY PEfi50N IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
N WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
= SU&IECTTOTHEWORKERS'CAMPENSATIONPROVISIONSOFSECTION37000FTHELABOR
CODE,I SHALL FOflTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
� SMIP
p DATE: APPLICANT.
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SUBJECTANEMPLOVERTOCRIMINALPENAL7IESANDCIVILFINESUPTOONEMUNDREDTHOUSAND ENERGYPERMIT
DOlLAqS(S7o0,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SEC710N37o80FTHELABORCODE,INTERE57,ANDATTORNEY'SFEES. RETENTIONFEE: • v
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� CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERJUfiV THAT THERE IS A CANS7RUC710N LEN�ING AGENCY
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.).
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� LENOER'S NAME
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w ICERTIFVTHATIHAVEPEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ��� � �� I
� I AGREE TO COMPLV WITH ALL CITV AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBV AU7HORIZE REPRESEN7A71VES OF THIS COUNTY TO ENTER UPON THE
Z ABOVE�MENTIONED PROP RTV FOR INSPECTION PURPOSES. COMMENTS �
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N SIGNATUREOFPE E DA7E
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL ; j FHA REQMTS
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SLAB GRADE _ __ ____._I_FIREPLACE FOUNDATION_
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TEMP POWER .---��_.._._ __._I FIREPLACE B�ND BEAM-- �--_________.,
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SHOWER/TUB TEST ' POOL ELEGTRIC ___ _
EXT. LATH/SIDIfVG �POOL FENCING
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WALL INSULATION � POOL FINAL �
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CEILIIVG IIV�ULATION j OFF SITE 1�1l1PS.
DRYWALL NAIUNG DEDICATIOiVS
SEWER FINAL ENG. . '
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
— - �--._...______ __.- - ----
GAS AIR TEST FINAL ZONING
FINAL CONST. �'!RE DEPT. FINA�
FIf�AL HEATING ! HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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FihlAL PLUMBING � ENERGY
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