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_�� CITY OF DIAMOND BAR I
DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)86Q3195 Fax(909)861-3117 PRESS
����'� BUII.DING PERMIT APPLICATION FIRMLY
} JOBSITE � APPLICATION ; � PERMfT P/C
o ADDRESS �� O� S_ S�t>l b� ;a h�- DATE � I NUMBER•- #
� ISSUE- ' � JYPE � OCC
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p ADDRESS ' � ZONING SETBACKS
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� CONTRACTOR SIDE ❑
� ADDRESS
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�n DESCRIPTION SQ:.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFIRM UNDER PENALTY OF PERAIRV THAT I AM EXEMPT FROM THE CONTMCTORS LI- Gef99B/CBfPOfI
W CENSEUWFOR7HEFOIlOWINOREASON(SEC.7031.6BUSWESSANDPROFESSIONSCOOEANVGTYOR (n -
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LL� TURE,PRqH TO fT3 133UANCE.AL50 REW IRE9 THE APPLICANT FOR SUCH PERMIT TO FlLE A SIONED W Patio/Deck
STA7EMEHT THAT HE OR SHE IS LICENSED PUfiSUANT TO THE PROVISIONS OF THE CONiRACTORS LI-
� CENSE LAW(CHAPTER G(COMMENCMO WITI SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- � PooUSpa � �
FESSIONSCOO�ORTHATHEORSHEISEXEMPTTHEREFHOMMlD7HEBASISFOR7HEALlEOEDE7CEMP- (!j
TIp1.ANY V10LATqH OF SECTION 7091.6 BYANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT T0 Z Re-Roof- '+
� ACML VENAL7Y OF NOT MORE THAN FIVE HUNDRED DOLURS(i600).): .
� ❑I,ASOWNEROFTHEPROPERTV,ORA1vEMPLOVEESMnTNwAOESASTHEIq50LECOMPENSA710N, COmrtI9fCl81 �
WILL 00 TNE WORI(,ANO THE STRUCTURE IS NOT IMENOED OR OFFERED FOR SALE(SEC.704t,BU51- �J
� NE53 AND PqOFE5S10N5 QOOE:THE CONTRACTOqS LICENSE LAw DOES NOT MPLV 70 AN OWNER OF �
PROPERTY WFIO BUBD$OR IMPROVES TNEREON.AND WHO DOES SUp1 WORK HIMSELF OR HERSELF OR
Q iT1iqUGH MIS OR NER ONT1 EYPLOYEES,PROVIDED THAT SIX:H IMPROVEMENTS ARE NO7INTENDED OR m
� OFFERIDPDRSALEIF,/pWEVER7NEBULDRIC�ORIMVROVEMBfTIS50LDWfTHBdONEYEAROFCAMpLE-
Z �'TION,THE OWNER-BUILDER WILL HAVE TME BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� W P VE FOR THE PUHPOSE OF SALE}
� � ASOWNEROFTHEPROPERtV,AME%CLUSIVELYCONTMCTINOWfiMLICENSEDCONTMCTORS
TO TRUCT THE PRQIECT(SEC.7041,BUSINESS MID PROFESSIONS CODE 1HE CONiRACTORS U- V8IU81{Ofl ADJ.AREA
CEN9E UW DOE3 NOT MPLV TO AN OWNER OF A PROPERTV WFIO BUttDS OR BAPROVE9 7HEREON,AND
� W/1000NTRACTSFORSUq1PR0.1ECT5WfTHACONiRACfOR(S�LICENSEDPURSUAMTOTNECONTMG QUANTITY DESCRIPTION FEE �
� TORSIJCENSELAW.),
❑I AM IXEM7T UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� DATE � OWNER '� �
Z W
� UCENSEO CONTRACTORS DECLAAATION W
� I HEREBV AFFIRAI UNDER PENALTV OF PERAIRY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER Ur
s Y(COMMENC7Ni WIT1 SECTION 7000)OF DMSION 3 OF TME BUSINESS AND PROFESSIONS CODE,AND Z
X. W LICENSE 45 M FULL FOHCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFlRM UNDER PENALTY OF PE0.NRY ONE OF THE WLLOW WG DECURATIONS: Z
� _IHAVEANDWILLMANITNNACERTIFlCATEOFCONSENTTOSELf-INSUREFORWORKERS' _
Q COMPENSATION.�l5 PROV�ED BY SECTION J7000F THE LABOR CODE,f-0R THE PERFOqAIANCE U
Q ' OF THE WORK fOR VMlqi THIS PERMR IS ISSUED. �
_1 HAVE MID WILL M/JNTAPI WOW(ERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 37000F THE U80R CODE,FOR THE PERFORMANCE OF TFIE WOR)(FOR WHICH THIS PERMIT IS
ISSUm.MY WORKEAS'COMPENSATqN INSURANCE CARRIER AND POIICY NUMBER AfiE CONSTRUCTION �
jc+wAieA � PLAN REVIEW ,�
� POLICY NUMBER � .
Z . ELECTRIC
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� (I1iS6ECi1CXdP77E�NOT8EQJ1.P1.EfIDOfhEPEFi.RISfO{iONEHIR�DR�DOLLNS(5100)ORLESS} PLUMBING
Z I CERTIFY THAT W hiE PERFOHMANCE Of THE WORK FOR WHlpl THIS PEfiM1T IS ISSUED,I MECHANICAL
SHALL NO7 EMPLOY ANV PERSON W ANV MANNER SO AS TO BECOME SU&IECT 70 THE
(/� WORI(ERS'COMPENSATION UWS OF CALIFORN10..�ND AGREE TMAT IF I SHWLD BECOME INSPECTION FEE
S SU&IECT TO THE NfOfiNERS'COMPENSATION 7ROVISIONS OF SECTqN 3700 OF THE UBOR
CODE,I SHML FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
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� WARNINO:FAI�URE TO SEWRE WORKERS'COMPENSATION CAVERAOE IS UNUWFUL,AND SHALL BE ENERGY P/C
�y SUaIECTMIEMPLOYERTOCRIMINALPENALTIESANDCNILFINESUPTOONEHUNDREDTHOUSMID ENERGYPERMIT �`i /1
OOlLARS(i100.000).IN/�DDI710N TO TNE C0.ST OF CAMPENSATION,DAM�OES AS PROVIDED FOR IN
� SECTION 9708 OF THE LABOH COOE,INTEREST,AND ATTORNEVS FEES. [ � I
RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PqE-ALT FEE: �TTY nF�[�j,�Q,��R AR
� I HEREBV AFFIRM UNOER PENALTY OF PERIURV THAT THERE IS A CONSTRUCTION LENDWO AGENCV T�
FOR THE PERFORMANCE OF THE WORK FOR WHICH TMIS VERMIT IS ISSUED(SEC.3087,CIV.C.�. , -
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� LENDERS NM1E
F- LENDER'SADDRE55
� I CEHTIFV THAT I HAVE HEND THIS APPLICATION AND STATE THAT THE ABOVE INFORAIATqN IS CORRECT. TOTAL FE ES O��
w I AGREE TO CAMVLV WITH ALL CITY M!D COUNTV ORDINANCES AND STATE LAWS RElATWO TO BUILDIN(3
� CONSTRUCT�ON,MJD HEREBV AU7HORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON 7HE
/�BOVE-MENTIONED PROPEHTY FOR INSPEGTION PURPOSES. .I
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N sw R OF PE u eE DATE RECPT.NO. PAID BY VALIDATION
~ WHITE-0epeAment Copy,YE110W--Finence Copy,PINK—Asaesaor Copy,GOLDENROD—File Copy,GREEN—ApplicanY Copy
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SLAB GFiADE FIREPLAGE FOUhIDATION • �
TEMP POWEft FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING � p( � 8 FL BOND BEAM
FRAMINGNENTILIATION $-s$ FINAL SOND BEAM
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ROUGH HEATING ��� BENCHING
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ROUGH PLUIvIBIt�G �`�-esi, FINISH GRADiNG
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