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CITY OF DIAMOND BAR �x ` C r I
--��� DEPARTMENT OF COMMUNITY Bt DEVELOPMENT SERVICES �
21660 E.Copley Drive Suite 190 �
(909),860-3195 Fax(909)861-3117 �RESS
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APN LOT� TRACT DATE V� �� CONST. GROUP
p OWNER S�ts �,r� C :/�c: �N_`�. �
" ADDRESS IS� � _S'�P � .� � L IJ ZONING SEBACKS
� CITY 1 - . t�v ZIP�� TEL. REART RW ❑
APPLICANT ��£_� TEL "3 SIDE/SIDE STREET RW ❑
� CONTRACTOR -T���!+�.5 c� O 1�c L,�c�C:C.y a.� SIDE ❑
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� DESIGNER NO.DWEL.
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cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANAL ATION
p� OWNER-BUILDER DECLARATION SFRlADD/REM (� �yy (�(�
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I HEREBV AFFlRM UHDEH PENAL7V OF PERNRY THAT I AM EXEMPT FROM THE CONTMCTORS LI� G8f8
W CENSEUWPoRTHEFOLLOWINOREASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITYOR (n ,
U COUNf'fWHIdiRE0U1RESAPERMRTOCONSTRUCT,ALTER,IMPROVE.DEMOLISH,ORHEPAIRANVSTRUC- PyllO/DBCk '
L NRE,PRIOR TO ITS ISSUANCE,ALSO REW IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEAIENT THAT HE OR SHE iS L�CENSED PURSUANT TO THE PROVISIONS OF THE CON7RAC70RS LI-
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- �
FESSIONSOODE)ORTHATHEORSHEISEI(EMPT7HEREFROMANDTHEBASISFOHTHEALLEGEDEXEMP- (�
TION.AHYVIOLATIONOFSECTION7031.5BVANYAPPLICANTFORAPEFMITSUBJECTSTHEAPPLICAMTO Z Re-Roof
� A CML PENAL7Y OF NO7 MORE 7HAN FNE HUNORED DOLURS(i500).j:
� �I,ASONMEROFTHEPROPERTV,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSA7qN, � Commercial . –
MALL DO THE WORK,AND THE STRUCTUHE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70��,BU51� J
NE55 AND VROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NO7 APPLY 70 AN OWNER OF
;.� N PROPEqTYWIqBUIIDSORIMPROVESTHEREON,ANDNMODOESSUCHWORKHIAISELFORHERSELFOR �
Q THHOUGH HIS OR HER OWN EMPLOYEES,PROVIDE�THAT SUpI IMPROVEMENTS ARE NOT IN7ENDED OR m
QOFFEREDFORSALEIF,HOWEVERTMEBUILDINOORIMPROVEMENTISSOLDWITHINONEYEAROFCAMPLE-
Z �'TqN,THE OWNER�BUIIDER WILL HAVE THE BUHDEN OF PROVINO 7HAT HE OR SHE DID NOT 9UIlD OR
� IMPiqVE FOR THE PURPOSE OF SALE).
w ❑I,AS OWNER OF iHE PROPENTV,AM E%CIUSNELV COHTRACTING N7TH LICENSED COHTRACTORS
[t TO CONSTRUCT THE PRQIECT(SEC.70N,BUSINESS ANO PROFESSIONS CODE:TME CONTRACTORS LI- VelUef1011 ADJ.AREA
lll CENSE UW DOES NOTAPPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
� NRIOCOMMCTSFORSUp1PRQ1ECTSWITNACONTMCTOR(5)UCENSEDPURSUAMTOTHECONTMG QUANTITY DESCRIPTION FEE � �
� TORS LICENSE UW.). �
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Q ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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Z OATE OWNER U L � �
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� UCENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIIiM UNDER PEN/�LTV OF PERIURY THAT I MI LICENSED UNDER PROVISIONS OF CHAPTER �
d Y(COMMENCINO WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND Z
X. MY LICENSE IS IN FULL FORCE M1D EFFEC7.
� IICENSE CLASS � LIC.N0. (�� .{/ � S / j
� V DATE II� '—J��-—O a CONTRACTOR J � :L N a
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� WORKERS'COMPENSATION DECLARATION � �
� I HEREBY UNDER PENAL7V OF PERIURV ONE OF THE FOLLOWING DECLARA7qNS: Z ti
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� �IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORV/ORKERS' _
COMPENSATION,AS PROVIDED BV SEC710N 370o OF THE UBOR CODE,FOR 7HE PERFOqMANCE U
Q OF THE WORK FOR NMIp1 THIS PEHMIT IS ISSUED. �
�
_I HAVE AND WILL MAIHTAIN WOf1KERS'COMPENSA710N INSURANCE,AS REOUIRED BV SECTION ///���
Q 3700 OF TNE UBOR COOE,FOR THE PERFOHMANCE OF THE WORN FOR WHICH THIS PERMIT IS �
ISSUED.MY WORKERS'COMPENSATION INSUHANCE CARRIEH AND POLICY NUMBER ARE: CONSTRUCTION �
jCARRIER ��'���� �-�c�I PLAN REVIEW y ,�7 ��
� POLICY NUMBER /�7--/., L i.L S�1—�� ELECTRIC 7�Lil_/
� (i}GSSEcrqNNE�raisEoob�LErIDOFiHEFEA.siSFORa+EHIY�DREU�OUARs(5100)ORLEss} PLUMBING
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Z I CERTIFY h1AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
(� SMALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO TF1E
N WORKERS'COMPENSA710N LAWS OF CALIFORNI/�AND AGFEE THAT IF I SHOULD BECAME INSPECTION FEE
SUBJECT TO THE WOHKERS'COMPENSATIO�N P OVISIONS OF SECTION 370o OF THE IABOF
S CODE,1 SHALL FORTHWITH COMPLV WI7H T^�`' PRO SioNs. ISSUANCE �L /�
p DATE: 6 �I ' J APPLICANT: J c .f�� J SMIP �'SC�
J WARNINO:FAILURE 70 SECURE WORKERS'CAMPENSATION CAVEHAGE IS UNUWFUL,AND SH/�LL BE ENERGY P/C
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDHED THOUSAND ENERGY PERMIT
DOLLARS(i700,o00).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOH IN
� SEC7qN 37oB OF THE UBOR CODE.INTEREST,AND A770RNE1^5 FEES. � RETENTION FEE:
OCONSTRUCTIONLENDINGAGENCY PRE-�L F E:
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUC710N LENDING AGENCY
d FOR THE PERWRMANCE OF THE WORK f-0R WHICH THIS PERMI7IS ISSUED(SEC.30Y7.CIV.C.). �
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� LENDER'S NAME - �
� LENDER'SADDRE55 r /
� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOfiMATIONISCORRECT. TOTAL FEES , /'/,
w I AGREE 70 COMPLV WITH ALL CRV AND COUNTY ORDINANCES AND STATE UWS RELATING 70 BUILDING ��
� CONSTRUCTION,AND HEREBY AUTFIORIZE REPRESEN7ATIVES OF 7HI5 CAUNTV TO ENTER UPON THE . /� ��
ZABOVE-MEHTIONED PROPEHTI'FOR INSPECTION PURPOSES. COM TS � ��" �
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� � RECPT.NO. PAID BY " VALIDATION
� --�- W E—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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SET BAGK � j . I FLOOR JOIST
FTGS/FORMS/STEEL /� I L� � . � FHA REQMTS ' �
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ELECTRIC GROUND ' UNDER FLOOR DUCT
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GROUND PLUMBING I _ � UNDE� FLOOR CUt�IDUIT �
_ - ----- -_ --.............._._....--
SLAB GRADE FIREPL:ACE FOI�NDATION � _
TEMP POWER __ ._ � __ FIREPLACE 80ND BEAM � __
WATER SERVICE � MIQ HT. BOND BEAM
R �SHEATHING -Z2 8 Ff. BOND BEAM
---��i!__._ -- -----------
FRAMINGNENTILIATION I �2/S�p ' ' ` . ', FINAL BOND BEAM
ROOF COVER � � PRE-GRADING
ROUGH HEATING � BENCHING
ROUGH ELEGTRIC �"LIS Dd ROUGH GRADING ____ _,___
ROUGH P�UMBING —�_�_ ' FINISH GRADiNG ^
SHOWER/TUB TEST �OOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL WSULATION , POOL FINAL u _, _
CEILING IIVSU�ATION � OFF SITE IMPS.
� DRYWAL.L NAILING DEDICATIONS �_ _ _.,� L,
� 5EWER � FINAL ENG. �
SEPTIC TAIVK �AIVDSCAPE/IRRIG.
SEEP P!T/L.L. ON SfTE IMF'S. �
GAS A!R TEST FlNAL ZONING ` •
FINAL CONST. � FIRE DEP7. Fi(vi�L ____ �__
� F1N�1!HEATiNG . HEALTH DEPT. FINAL
FiNAL ELEGTRIC � � J � GEV. FEES PAID ---_.��_ _-----------
i=1NAL PLUMBING ENERGY
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SEPTIC TANK SIZE ' '
SEEP PIT/U SIZE -- — ----------_ _.._-----..__-----
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