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� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVI S
� 21660 E.Copley Drive Suite 190 �
(909)86Q3195 Fax(909)'861-3117 PRESS
•�'^^'.+� BUII,DING PERMIT APPLICATION. ' FIRMLY
} JOBSITE Z��s'"� r���G����,� �L. APPLICATION�I� �PERMIT 11 u( P/C��
o ADDRESS_ �� DATE �2 s e NUMBER_L��___�J#
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� DESIGNER �- LT � NO.DWEL. NO. � NO. /
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAN ATION
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p I HEREBV AFFlRY UHDER PENALTY OF VERIURY THAT I MI E%EMPT FROM THE CONTRACTOqS LI- GefOgB/CefpOff J�
IL CENSEUWFORTHEFOLLWJ410REA,90N(SEC.7o31.6BUSINESSANDVROFESSIONSCODE:ANYCITYOR (n � � V
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�� TUfiE.PRIOR TO�T8 ISSUANCE.ALSO REOUIPES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w �
9TATEMENT THAT HE OR SHE IS LICENSED PURSUMlT TO THE PROVISIONS OF THE OONTRACTORS.LI�
� CElISE UW(CHAPTER Y(COMMENCWO WITH SECTION 7000)OF DMSION�OF THE BU91NE55 AND Pq0. � POOUSpB
FE59qN9COO�ORTHATHEORSHEISIXEMPT7HEREFROMIWDTMEBASISFORTHEAILEOEDEXEM0. . (�
TION.AHVVIOLATIONOFSEC710N7o3t.6BVANVAPPLICMlTf-0qAVERMI75UBJECT57HEMPLICANT70 Z Re-Rooi
� ACML PENAL7Y OF NOT MORE h1M1 FIVE HUNDRED DOLLARS({60D).):
� ❑I,ASOWNEROFTHEPROPER7Y,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSA710N, � �mmercial . � '
WILL DO THE WORK AND THE 97RUCTURE IS NOT INTENDED OR OFFERED FOR 5/�LE(SEC.7oN,BU51� J
� HESS AHD VROFESSIONB COOE:THE CONTMCTORS LICENSE UW DOES NO7 APPLY TO AN OWNER OF �
VROPERTY WMO BUILD9 OR IMPROVES 7HEREON,AND NT10 DOES SUCH WOFIN HIMSELF OR HERSELF OR �
WTHROUOM HIS OR HER OWN EMROYEES,PROVI�ED hUT SUqi WPROVEMENTS ARE NOT INTENDED OR m
Q OFFEREDFORSALEIF,HOWEVERTMEBULDINOORIMPROVEMENT1950�DN77}i1NONEVEAROFCOMPLE-
Z �'7qN,THE OWNER�BUILDER WILL HAVE 7ME BURDEN OF PROVINO 7Y1AT HE OR SHE DID NOT BUIID OR
� P/PROVE FOR THE PUHP0.5E OF SALE). .
�yJ ❑4��M�NEROF THE PROPEHfV,AM D(CIUSNELY CON7RACTPIO N7TH LICENSED CONTRACTOqS
[C i0 CUNSTRUCT THE PRQIECT(SEC.70N,BUSIHESS AND PROFESSIONS CODE:THE CONTRACTORS ll� V81U0SI0l1 ADJ.AREA
LLI CENSEUWDOESNO7MPLVTOANOWNEROFAPROPERTYWFqBUttD50qIMPqOVESTTIEREON,AND
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LICENSED CONTRACTORS DECLARATION W
� 1 HEREBY AFFIRAI UNDER PENALTY OF PEfUURV hIAT 1 AM LICENSED UNDER PROVISKKJS OF CNAP7ER y�.�
� Y(CO�IMENCUX7 WfTH SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PROFESSKKJS CODE,AND Z XTV'`-L V���T
W LICENSE IS 41 FUl WRCEAND EFFECT. m � �_� � �•� �
� LICENSE CLASS � UC.NO. J ��G�I F'f . � - �
� ontE c��� n 1 CONTRACTORCy�I�R—'r� ��/�tl a � 171s�'�'�N'�YL �, �
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0� WORKERS'COMPENSATION DECLAAATION WNS'r'��L'C\ 11 �.
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� 1 MEREBV AFFlRM UHDER PENAISV OF PEFLIURV ONE OF THE FOLLOWING DECURATIONS: Z , , (� '
� _I HAVE AND WILL MAMTAIN A CEfiTIFIGTE OF CONSENT TO SELF-INSURE FOR NqRKERS' a � „ , '
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COMPENSATION,AS PROV�ED BV SECTION 370o OF TME LA80R COOE,FOR THE PERFORM�f10E `U
Q OF 7NE WOR1C FOR WHICM THIS PERMIT IS I$$UED. � , . � ' �
� �I HAVE AND WILL MMfrAIN WORKERS'CAMPENSATION INSURANCE,AS REOUIRED BV SECTqN ��� �
QQ 3700 OF THE LA80R CODE,FOR THE PERFORAIANCE OF TFIE WORK WR WHICH THIS 7ERMIT IS
ISSUED.YY M10rRKER5'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
jCAHRIER 1�_�N{p PLANREVIEW 3 a
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0 (naSSEcrorar€�r+o79Eaa.RE7IDOFn�aeaKisFOaatJEFAX�DR�oouus(s�oo)aaLEss�. PIUMBING
Z I CERTIFV THAT IN h1E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL `
(�' SHALL NOT EMPLOV ANV PERSON W ANY MANNER SO AS TO BECOME SU&IECT 707HE
(q WOPo(ERS'COMPENSATqNUWSOFCALIFORNIA,ANDAGREETHATIFISHOUIDBECOME INSPECTIONFEE
SUBJECT TO THE WORKERS'COMPENSATqN PROVISIONS OF SECTION 37o00F THE L/�BOR
coo�,i srw.�Foarrrvnn�coMv�r win+nase aaov�sror+s. ISSUANCE
p DATE:�� APPLICANT:an,Ul-Y��.-� T L1�"l C-ONrV��,�� �SMIP �%•
w ENERGY P/C � - � �
� WARNINO:FAILUHE TO SECURE WORKERS'COMPEN9ATqN COVERAOE IS UNUWFUL,M1D SHALL BE .. �/� .
� SUBJECTMI EMPLOVER TO CAtM WAL PENALTIES AND CIVIL FWES UP 700NE HUPIDRED TFIOUSMIO V
DOLLARS(i100.000),INADD1110NTOTHEC0570FCOMPENSATION,DAMAOESASPROVIDEDFORIN ENERGYPERMIT ,�, I
I � SECTION 370!OF THE U100R CODE.MTEREST,AND ATfONNEVS FEES. ' RETENTION FEE: ���� �- �-' �"`� �/��.��_JJJ
� CONSTRUCTION LENDING AGENCY pR T E• y'
� I HEREBV AFFIRM UNDER PEN/�LTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AOENCV � ' I
d FOR THE PERFORMANCE OF THE WOR)(FOR WHICFI TMIS PERMIT IS ISSUED(SEC.30Y7,CIV.CJ. - � .
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� LENDER'S NMIE
� LENDER'S ADDRESS /� . . �
� I CERTIFY THAT I MAVE READ THIS APPLICATKKJ AND STATE THAT THE ABOVE INFORMATqN IS CORRECT. TOTAL FE ES �l/t��O-� . � �"
W I AOREE TO COMPLV N7TH/�Ll CITY AND COUNTY ORDINANCES AND STATE UWS RELATINO TO WRDINO '
� CONSTRUCTION,M1D HEREBY AUTHORIZE REPFESENTA7NE5 OF 7HI5 COUNTY TO EMER UPON TNE � � '
�. ABOVE�MEMIONED PROPERTY FOR INSPECTION WRPOSES. COMMENTS �
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m PERMITTEE NAME(PRIIlf) ' '
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N SI6HANRE fT7EE DATE � � �
� � � RECPL NO. PAID BY � VALIDATION '
ITE—Depertment Copy,VELLOW—Ffnence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicanfs Copy
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GRC�UND PLUMBING UNDER FLOOR CUt�IDUIT � "' ' �
SLAB GRADE FIREPL`ACE'FOUNDATION
TEMP POWER FIREPLAGE BOND BEAM • L� ' � �
WATER SERV�CE MID HT. BOND BEAM
� ROOF SHEATHING � � --Z7i?� 8 FL BOND BEAM
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WALL INSUiATION POOL FINAL
CEILING INSULATION OFF SITE�MPS.
DRYWALL NAIUNG /- -o�/ QEDICATIONS
SEWER �� o FINAL ENG.
SEPTIC TANK � LANDSCAPE/IRRIG.
SE�P PIT/LL. ` ' ' ON SITE IMPS.
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F1NAl.C�NSY �'� d w � FIRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL�ELECTR{C �� DEV. FEES PAID
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