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_!� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
I � 21660 E.Copley Drive Suite 190 PRESS
,, (909)860-3195 Faz(409)861-3117
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� JOBSITE APPLICATION /`� PERMIT �j P/C �`� I�
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- G9f89B/C81p01I
W CENSEUWFOR7HEFOLLOWINOREASON(SEC.7o31.58USINESSANDPROFES510NSCODE:ANYCITYOR
U COUMYWHICl1RE0UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORFEPAIRANVSTRUC- �
Z TURE.PRpR TO ITS ISSUANCE,ALSO REWIRES THE APPLICAHT FOR SUCH PERMIT TO FILE A SIGNED w PafiO/DBCk
w STATEMENT hiAT HE OR SHE IS 110EN5E�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- w
� CENSE LAW(CHAPTER a(COMMENCINO WITH SEC710N 7ao0)OF DIVISION 3 OF THE BUSINESS AND PRO-- u' PooUSpa
FESSqNSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEOEDE%EMP• (�
TION.ANVVIOLATIONOFSECTION7031.6BVANYAPPLICANTFOSAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTY OF NOT MORE T11AH FIVE HUNDRED DOLURS(i500).):
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MALL 00 THE WORK AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7011,BUSI- J
� NESS AND PpOFESSIONS COOE:THE COHTRACTORS LiCENSE UW DOES NOT APPLY TO AN OWNER OF ?
PROPEHfY NMO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� iHRODUH HIS OR HER ONM EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTEN�ED OR m
w OFFEREDPDRS�LEIF,HOWEVEiLh1E8UILDINOORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
G TION,THE OWNER�UILDER WILL HAVE THE BURDEN OF PROVINO 7HA7 HE OR SHE OID NO7 BUILD OR�
Z IMPiIOVE FOR THE PURP0.SE OF SALE).
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Q TO CONSTRUCT THE PR0.1EC7(SEC.7aI,BUSINESS AND PROFESSIONS CODE:THE CONTMCTORS LI- V81U8ii0f1 ADJ.AAEA
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� M?1000NTRACTSFORSUCHPR0.IECTSWITHACONTMCTOR�S)LICENSEDPURSUANTTOTHECONTRAG pUANTITY DESCRIPTION FEE
� TORS 110EN5E LAWJ. •
� O I AM El(EMPT UNDER SEC. B.8 P.C.�FOR THIS HEASON Q
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DATE OVMER V
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTY OF PE0.IURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � .
� Y(COMMENCWOWfTHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,AND Z
X MY UCENSE IS IN FULL FORCE AND EFFECT.
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� WORKERS'COMPENSATION DECLAFATION Q
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� I ER Y AFFIRM UNDER PEN�LT/OF PERIURY ONE OF THE FOLLAWING DECLAMTIONS: Z
� I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSENT TO SELF-INSURE FOR WORNERS' 2
PENSATION,ASPROVIDEDBVSECTIONs7o00FTHELA80RCODE,FORTHEPERFORMANCE U
Q OF hIE WORK FOR WHICM THIS PERMIT IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMVENSA710N INSURANCE.AS REOUIRED BV SECTION ///'''���...///���
Q 9700 0F hIE LABOR WOE,FOR THE PERFORMANCE OF THE WORN WR WHICH THIS PERMIT 15 ��
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AN�POIICY NUMBER ARE: CONSTRUCTION /r�/�
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� POLICYNUMBER�,-R-1 �21 O S�O ELECTRIC
� (1TUSSECf1a�NE�No7eE00PWLEimOFnEPEwATSfORONEMx�OtimOou/�As(itoo)oaLFss} PIUMBING
Z I CERTIFY THAT IN THE PERFORMANCE OF THE WOHK FOR WHICH THIS PERMIT IS�SSUED,I MECHANICAL
(,'J SHALL NOT EMPLOY ANV PERSON IN ANY MhNNER SOAS TO BECAME SU&IECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THA71F I SHOULD BECOME INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR U
cooE.is�rrn�win�ca�a�rwmin+osEaaowsioNs. J ISSUANCE 7n�ife }?c�•
p DATE: � APPUCANT: � Ci! SMIP . � ��'�`�"� I
W ENERGY P/C �
J WARNINO:FAILURE 70 SECURE VADRKERS'COMPENSATION VERAGE IS UNUWFUL,AND SHALL BE (�, y
� � SU&IECT AN EMPIOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT N O e n1 FA6T�
r DOLLARS(i100,000).IN ADDIiION TO THE COSTOF COMPENSA710N,OAMAGES AS PROVIDED FOR IN - „ u
J SECTION 37oe OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: f�s'+-- �_ �
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a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: -_ rp�/`� p7��
� I HEREBY AFFIRM UNDER PENALTY OF 7ERlURV 7HA77HERE IS A CONSTRUCTION LENDING AGENCY �l��' +1`�l.1!'1.!V t l�'n�IF+G�TF7
d FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oB7,CIV.C.). - "
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� LENDER'S NAME �
H IENDER'SADDRESS
� I CERTIFY 7HAT I HAVE READ hIIS APPLICATION AtJD STATE THA7 THEABOVE INFORMATION IS CARRECT. TOTf1L FE ES �O�� '
W I A�REE TO COMPLV WITH ALL CRY M!D COUN7V OR�INANCES PND STATE UWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTA71VE5 OF THIS CAUN7Y 70 ENTER UPON THE C(� �/�
Q ABOVE�MENTIONED PqOPERTV FOR INSPECTION PURPOSES. �C�rr V Y p 21�pO- �,l/U l. dq•
Z COMMENTS � �►�
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� RECPT.NO. PAID BY VALIDATION
WHITE—Depertment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENROO--File Copy,GREEN—qpplj�nt's Copy
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GROUND PLUMBING UNDER FLOOR CU�IDUIT
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FtREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM �
ROOF SHEATHING 8 FC B�ND BEAM �
FRAMINGNENTILIATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUPNBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRlC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL '
CEILING INSULATION OFF SITE IMP5.
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK � LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FIfVAL CONST. FIRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FIIVAL ELECTRIC DEV. FEES PAID
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