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CITY OF DIAMOND BAR
t DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 2! I S QfY`et AAA0 D. O.
APN LOT TRACI
OWNER
ADD SS 1 f c•"r.t OMA, f
CITY ZIP Z2 S -TEL
APPLICANT
CONTRACTOR
ADDRESS
CITY ZIP TEL
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR 714E FOLLOWING REASON (SEG 7031.6 BUSSESSAND PROFESSIONS CODE. ANY CITY OR
COUHTYN7YCH REONRES A PERMITTOCONSTRLICT,ALTEFL IMPROVE, DEMOLISH, OR REPAIR ANY STRUG
TUPE. PPIOR TO RS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DMKO
SN 5 OF THE BE
AND PRO
FESSIDNS CDDE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXENP-
T10N. ANY VIOLATION OF SECTION 7071.5 BYANYAPPLIJJIT FOR A PERMIT SUBJECTS THE APPLICANT TO
A L MALTY OF NO'T MORE Ti W1 FIVE HUNDRED OOl1AR8 (f 5001 ):
AS OWNER OF 714E PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
IW E WORK, AND THE STRUCTURE i5 NOi N7ENOED O0. OFFERED FOR SALE (SEG 7M.. B1151
S ANO PFXOFESSIONS COTE THE CONTRACTORS INCENSE LAW DOES NOT APPLY TO AN ONNEfl OF
PROPERTY WMO BUILDS OR IMPROVES THEREON, AND VMO DOES SUCH WORK HIMSELF OR HERSELF OR
THROW HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
CFFERED FOR SALE 6, HOWCVER, THE BULDING ORIMPROVEMIDITIS SOLD%TnMNCNEYFAR OF MMPLE-
TION, THE OWNERAULOER WILL HAVE THE BURDEN OF PROVING THAT HE OR 511E DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SOLEI.
O L AS OWNER OF THE PROPERTY, AM EXCLUSNELY CONTRAL'TING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE', THE CONTRACTORS U -
CENSE LAW DOES NOT APPLY TORN OWNER OF A PROPERTY VA40 BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LICENSED PURSUANT TO THE CDNTRA6
TORS tICEIVSE LAW.).
O I AM EXEMPT UNDER SEG C. FO IS REASON
DATE T _OWNER
ICENSED CONTRACTORS D CLARATION
I HER AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISCN9 OF CHAPTER
of
CNG WITH SECTION 7000) OF DIVISION 7 OF TME BUSINESS AND PROFESSIONS CODE. AND
W UCENS TIN
FULL FORCE AND EfiECT.
LICENSE CLASS LIC. NO.
DATE COtITRACTOR
WO ERS'COMPENSATION DECLARATION
I HEREBY AFFIRM LNDCR PENAL PERJURY ONE OF THE FOLLOWING DECLARATIONS.
_ I HAVE AND WLL MAINTAIN A FI OF CONS ENT TO SELF -INSURE FOR WORK ERS'
COMPENSATION, AS PROVIDED B CTKJH77000FTHELABORCOOE, FORTMEPERFORMANCE
OF THE WORK FOR WHICH iHiS PE IS ISSUED.
�_I
HAVE AND WILL IMANTAIN WORK
ENSATKNN INSURANCE, AS REQUIRED BY SECTION
57000E THE LABOR CODE. FOR THE PER FO AN
OF THE WORK FOR WHICH THIS PE RMIT IS
ISSUED. MY YORKERS' COMPENSATION WSU CE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICYNUMBER �-
p3+55ECT1EN NEED NOT BE CONFUMOFTEPEi11.0T 6FOR ON HoaDDGUA0.; RIWl OR LESS,
1 CERTIFY THAT NTH EPERFORMANCCOFTHE W'E' OR WNECHT PERMIT6 LSSUED.1
SHALL NOT EMPLOY ANY PERSON NAVY MANNER SD AS TO BECOMES ECT 70 THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHQULD BECOME
SUBJECT TO THE WORKERS'COMPENSATIO N PROVISINS OF SECT10N 7700 OF THE LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS,
I
DATE: APPLICANT;
I
SUBJECT: N FAILURE TOSECURER I WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL THOUSAND SUBJECTAN EMPLOYE0. TO CRIMINAL PENALTIES AND CMLFWES UP TO ONE HUNDRED THOVSAND
DOLLARS (1100,000). INADDITION TOTHE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECT10NWN OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
L CONSTRUCTION LENDING AGENCY
i
1HEREBY AFFIRMUNDER PENALTYOFK Fort
THATTHEREIS L4ACONSUED(SEC. LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK iOR WHICH THIS PERMIT IS ISSUED (SFC. 3097. CIV C.).
1
LENDERS NAME
LENDERS ADDRESS
I 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFOnMATKNI IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HERESY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTION ED PROPERTY FOR INS PE PURPOSES.
S
011, -Min G} (_A
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'gas�- b
EOF PE TTEE D E
EXPIRED
DEC 2 71000 PRESS
FIRMLY
DATEAPPLICATION Z g�NUMB PERMIR / go P/C
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR p
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE . N
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFRIADDIREM
U)
Garage/Carport
W
Palio/Deck
LL
PooVSpa
Z
Re -Rost
Commercial "
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
U
H
U
W
W
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2
CO
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2
LU
S
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE •'D�
S�
SMTP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
0 S�
TOTAL FEES •
COMMENTS �• ,
t,ff ILL
RECPT NO. PAID B VALIDATION
WHITE—Department COPY, YELLOW—Finance COpy, PINK—Assessor ropy, LauwtNHUUr ENI L;opy. LIHLLr+– pp lCam 3 L,opy
CITY OF DIAMOND BAR
INSPECTION RECORD
e .e DA
SET BACK ; ,
OR INSPECTION DATE INSPECTOR
'• FLOOR JOIST
FTGS/FORMS/STEEL
FHA REQMTS
ELECTRIC GROUND
UNDER FLOOR DUCT. '
GROUND PLUMBING
UNDER FLOOR CONDUIT
SLAB GRADE
FIREPLACE. FOUNDATION -
TEMP POWER
FIREPLACE BOND BEAM
WATER SERVICE -
MID HT. BOND BEAM
ROOF SHEATHING
-- 8 FT. BOND BEAM
FRAMINGNENTILIATIb ' -
FINAL BOND BEAM
ROOF COVER
PRE -GRADING
-ROUGH HEATING
BENCHING
ROUGH ELECTRIC
ROUGH GRADING
ROUGH PLUMBING
FINISH GRADING
SHOWER/TUB TEST
POOL ELECTRIC
EXT. LATH/SIDING
POOL FENCING
WALL INSULATION
POOL FINAL
CEILING INSULATION
OFF SITE IMPS.
DRYWALL NAILING
DEDICATIONS
SEWER
FINAL ENG.
SEPTIC TANK
LANDSCAPE/IRRIG.
SEEP PIT/L.L.
ON SITE IMPS.
GAS AIR TEST-
FINAL ZONING
FINAL CONST.- -
FIRE DEPT. FINAL'
FINAL -HEATING
HEALTH -DEPT. FINAL
FINALELECTRIC
DEV. FEES PAID -"
FINAL PLUMBING
ENERGY
COMMENTS
C,E-71F. 41� =R •
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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