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CITY OF DIAMOND BAR � ,v � ��`� � � � ��l�� �
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�� 21825 E.Copley Drive ���1��'��g�,
(909)860-3195 Fax(909)861-3117 B•� PRESS
"'-���" BUILDING PERMIT APPLICATION �, , : ;, . ;,� FIRMLY
� JOBSITE C, � APPLICATION PERMIT P/C
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a ISSUE -7 TYPE OCC
^° APN LOT TRACT DATE � / - ��,� CONST. GROUP
p OWNER
� ADDRESS ZONING SETBACKS
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBY AFFIRM UNDEfi PENALTY OF PERJURV THA7 I AM EXEMPT FROM THE CON C70RS LI� Gef89B/CBIPOR
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w TURE,PRIOR TO ITS ISSUANCE,AL50 RE�UIfiES 7HE APPLICANT FOR SUCH P IT TO FILE A SIGNED w Patio/Deck
STA7EMENT THA7 HE OR SHE IS LICENSED PURSUANT TO THE PROVISION THE CONTRACTORS LI�
� CENSE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISI OF THE BUSINESS AND PRO� � Pool/Spa
FESSIONSCADE)ORTHATHEORSHEISEXEMPTTHEREFROMANDT ASISFORTHEALLEGEDE%EMP- (�
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Z WILL�O THE WORK,AND THE ST U URE IS NOT I DED OR OFFEFiED FOR SALE(SEC.7odt,BUSI� J
� NE55 AND PROFESSIONS CAD H ONTRACT LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPERTVWHOBUILDSORIMP V STHERE ,ANDNTiODOESSUCHWORKHIMSELFORHERSELFOR
� THROUGM HIS OR HER OWN E ES,P VIDED THAT SUCH IMPROVEMEN7S ARE NOT INTENDED OR m
QOFFEREDFORSALE.IF,HOWEV R,iHE DING�1RIMPROVEMEN7ISSOLDWITHINONEYEAROFCOMPLE-
Z TION,THE OWNEF�BUILDER WILL H THE BIJ�yN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� IMPROVEFORTHEPURPOSEOF E). •r"'�
w O I,AS ONRJER OF THE P PEFiTV,AM EXCLU5IVELV CANTRACTING W1TH LICENSED CANTRACTORS
� TO CANSTRUCT THE PR T(SEC.7o�t,BUSINESS AND PROFESSIONS CODE:THE CONTRACTOFiS LI� V21118�1Of1 ADJ.AREA
W CENSE UW DOES NOT PLV 70 AN ONMER OF A PROPERTV WHO BUILDS OR IMPROVES THEREON,AND
� WHOCANTRACTSF SUCHPRQIECTSWITHACONTRACTOR(S�LICENSEDPURSUAN7TOTHECONTRAC- --, qUANTITY DESCAIPTION � FEE
Y TORS LICENSE .). /
� ❑I XEMPT UNOER SEC. B.8 P.C.FOR THIS REASON� Q I � �' .� IJ��L
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� LICENSED CONTRACTORS DECLARATION w.
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I HEREBY AFFIRM UNDER PENALTV OF PER.IURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
X MV LICENSE IS IN FULL FORCE AND EFFECT.
� UCENSE C S/$ �f LIC.NO. ��/��(✓ j
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� WORKERS'COMPENSATION DECLARATION Q
� I HEHEBV AFFIRM UNDER PENALTV OF PERIURV ONE OFTHE FOLLAWING DECURATIONS: Z ,
Z _I HAVEAND WILLMAINTAIN ACEiiTIFICATE OF CONSENTTO SELF-INSURE FOR WOFiKERS' _
Q CAMPENSATION,AS PROVIDED BV SEC710N a7oo OF7HE LABOR CODE,FOR 7HE PERFORMnNCE W
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w �I HAVE AND WILL MAINTAIN WOPKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WOR RSJ'Qb�MPEN/�1''���N IN_SU�RANCE CAR/RIER'A-ND OLICY NUMBEfiARE: CONSTRUCTION
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WATER SERVICE � MID HT. BOND BEAM _ _
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SHOWERITUB TEST ' 1 POOL�LECTRIC
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WAIL INSULATI(7N ; POOL F�NAL !
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DRYWALL N,4ILING DEDICATIOPVS I
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SEWER FINAL ENG. '
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