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1� CITY OF DIAMOND BAR EXPIRED
DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 ^,� 9
(909)86Q3195 Fax(909)861-3117 I•'Ar �9 1OOJ PRE$S
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�-`A^'� BUILDING.PERMIT APPLICATION. .__ • FIRMLY
o ^ADDRIESS � 1 a CJ� �vti`7 E� yCC Si�/��C DATEICATIO� �� � NUMBER #/C OO—
� ISSUE TYPE OCC
APN LOT TRACT DATE � CONST. GROUP
p OWNE��SC�/1/C�/� � f//E�
ADDRES �l/ - � � ZONING SETBACKS
Z CITY � ZIP���TEL. O" _ REART RW p
� APPLICANT � �r � TEL.
- SIDE/SIDE STREEf RW O
� CONTRACTOR SIDE ❑
Q ADDRESS
� CITY ZIP TEL. PROPOSED USE
o ARCH/ENG/ ,
� DESIGNER NO.DWEL. NO. NO.
ADDRESS UNITS STORIES BEDROOMS
� CIN ZIP TEL.
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFlRM UHDEH PENALTY OF PE0.NRY THAT I AM EXEMPT FROM THE CONTMCTORS LI- GBfdQB/CBfpOff
W CENSELAWWRTHEFOILOWINGREASON(SEC.7037.58USINESSANDPROFESSIONSCODE:AIJVCI7VOR (n I
U COUHfYWHICMREOUIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- PeflO/DBCk I
� TURE,PRqR TO ITS ISSUANCE,ALSO REOUIRES iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W (
STATEMENT THAT HE OR SHE IS LICENSED PU{LSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE UW(CHAP7ER Y(COMMENCINO WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPe
FESSIONSOODE)ORTIIATHEORSHEISEXEAIPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (�
TIDN.ANYVIOLATIONOFSECTION70.77.50VAHYAPPLICANTFORAPERMITSU&lECTSTHEAPPLICAHTTO Z Re-Raoi
� A CML PENAL7Y OF NOT MORE THAN FNE HUNDRED DO�URS(f5ao).):
� �I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, � COITIfilOfClfl1 . �
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOH SALE(SEC.701l,BUSI- J
� NESS AND PROFESSIONS CODE:THE CANTMC70RS LICENSE UW DOES NOT APPLV TO AN OWNEH OF �
PROPEHfV NRIO BURDS OR IMPROVES THEHEON,AND NMO DOES SUCH WORK HIMSELF OR HERSELF OR
Q TMROUOM HIS OR HER ONM EMPLOVEES,VROVIDED 7HAT SUCN IMPROVEMENTS AfiE NOT INTENDED OH m
0 ,OFFEREDFORSALEIF,FIOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWfTHINONEYEAROFCOMPLE-
Z `TION,THE OWNER�BUILDER VALL HAVE THE BURDEN OF PROVIN�THAT HE OR SHE DID NOT BUILD OR
� IAIPROVE FOR THE PURPOSE OF S�LEj.
W ❑I,AS OWHER OF THE PROPEHTI;AM E%CIUSIVELV CANTMCTINA WITH LICENSED COHTRAC70RS
Q TO CONSTRUCT THE PRQIECT(SEC.70N,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81Ufl11011 ADJ.AREA
� CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVVMOBUILDSORIMPROVESTHEREON,AND
NM1IOCOHTRACTSFORSUCHPR0.IECTSWITIACONTRACTOR(5)LICENSEDPURSUM1TTOhIECONTMG QUANTITY DESCRIPTION FEE
Y TORS LICENSE LAW.).
� O I AM El(EMPT UNDER SEC. 8.6 P.0.FOR THIS REASON Q -
3 �
� ¢
�ATE ONMER U
O W
F LICENSED CONTRACTORS DECLARATION W
� 1 HEHEBYAFFIRII UNDER PENAL7V OF PERIURY hiAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
d Y(COMMENCINO WITH SECTION 7000)OF DIVISION J OF THE BUSINESS AND PROFESSIONS CADE.AND Z
X A/Y IICENSE IS IN FULL fORCE AND EFFECT. m
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� LICENSE CLASS LIC.NO. j
� J
V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOUAWING DECURATIONS: Z
� _I HAVE AND WILL MAINTAIN A CEfiTIFICATE OF CANSENT TO SELF-INSURE FOR WORKERS' _ �
COMPENSATION,AS PROVIDED BV SECTION 970o OF 7HE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WOflK FOR WHICH THIS PERMIT IS ISSUED. �
�
_I HAVE AND WILL AWNTNN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SEC710N ` /�
Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS /
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER/J1D POLICV NUMBER ARE: CONSTRUCTION f
jC�RRiER - PLAN REVIEW
Z POLiCV NUMBER ELECTRIC
Q �� (fH6SECf10NNE�NDTBE00h4'LEfIDOFhEPEFARISibRONEFiUFDREDWLIARS(f10D)ORLESS} PLUMBING �
Z I CERTIFY THAT IN THE PERFORMANCE OF THE MIOFK FOR WHICH 7HI5 PEHMIT IS ISSUED,I MECHANICAL �
(�J SH/U1 NOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECAME SUBJECT TO THE t
� WOfiKEHS'CAMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IP I SHOUID BECOME INSPECTION FEE r����S rS�r:�
SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR .Ll�"'y��
rj CADE,I SHALL FOHTHWIhi COMPLV WITH 7HOSE P OVI N.^ ISSUANCE � I
� � � SMIP e
p DATE: O APPLICANT: �
� ENERGY P/C ��� n fl �DPII�Of�
J WARNINO:FAILURE 70 SECURE WOFKERS'COMPENS TI CAVERAGE IS UNUWNL,AND SHALL BE - - • " Z 6 V FY V
� LL SU6IECT Ml EMPLOYER TO CRIMINAL PENAL7IES AND CIVIL FINES UP 70 ONE HUNORED THOUSAND ENERGY PERMIT�d
DOLLARS(i10o,000),IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN a p �pry, (�{�}��7�
J SEC710N37oBOFTHELABORCODE,INTERE57,ANDATTORNEV'SFEES. � RETENTIONFEE: riy g� vr LY1!'ll1+IA�J•`��j�
d CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: �`�`�'ll�v�"��SNi'L'.�
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV 7HA77HERE IS A CONSTRUC710N LENDING AGENCY �
FOR THE PERFORMANCE OF 7HE WOHK FOR WHICH THIS PERMI7 IS ISSUED(SEC.3007,CIV.C.). .
Z
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� LENDER'S NAME
F_- LENOER'SADORESS , � '
� I CERTIFY THAT I HAVE READ TFIIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �
� I AGREE TO CAMPLV N7TH ALL CfTY AND COUNTV ORDINANCES AND STATE UWS REUTING 70 BUILDING �(�
� CONSTRUC710N,AND HEREBV AUT}IORIZE REPHESENTATIVES OF THIS COUNTY TO ENTER UPON THE � �I"
Z ABOVE-MENTIONED VROPERTY FOR INSPECT N PURPOSES. COM S � �i�
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QPERMITTE E 1 ��1 _
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= RECPT.N0. PAID BY VALIDATION�
~ WHITE—DepeRment Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL � Z j� • ' FHA RE�MTS
ELECTRlC GROUND _ � UNDER FLOGR DUCT - _ � ^_
GR�UND PLUMBING ► __ UNDER FLOOR CU�IDUIT ; �. _ _ ________
SLAB GRADE FIREPLACE FOUNDATION _ -` ____
TEMP POWER FIREPLACE BOND BEAM - _ _
WATER SERVICE MID HT. BOND BEAM __
ROOF SHEATHING � �� 8 FT. BOND BEAM _____
FRAMINGNENTILIATION O=LZ FINAL BOND BEAM _ _ _
ROOF COVER PRE-GRADING ;
Rdl1UH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUN161NG FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. iATHiSIDiNG � POOL FENCING � `__ A I -
WALL INSULATION � POOL FINAL _, y
CEILING INSULATION OFF SITE 1MPS.
DRYWALL NAILING DEDICATIONS �
SEWER FINAL ENG. ------
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PfT/LL. � ON SITE IMPS. !
GAS AIR TEST FINAI.ZONING
FINAL C�NST. FIRE DEPT. FINAL
FlNAL HEATING HEALTH DEPT. FINAL �
FiNAL ELECTRIC DEV. FEES PAID ^ A
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