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_�rt� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
� 21660 E.Copley Drive Suite 190 J „
' (909)860-3195 Fax(909)861-3117 PRESS
������ BUILDING PERMIT APPLICATION � FIRMLY
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APN LOT TfiACT DATE CONST. GROUP
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CITY ;T'_/���j� ZIP�2�i TEL' PROPOSEO USE �� S� C�1�I�LC:`rZ. �i . ,
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� ADDRESS UNITS ' STORIES BEDROOMS
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y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADDIREM
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� �'I HEREBV AFFIRAI UNDER PENALTY OF PERNRV THAT I AM EXEMPT FROM THE CONTMCTORS LI- � Garage/Carport
W CEHSEUWFORTHEFOLLOWINGREASON(SEC.7037.58USINESSANDPROFESSIONSCODE:ANYCITYOR
U COUHTI'WHICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTAUC-� W patio/Deck '
� NRE,PRpR TO ITS ISSUANCE,ALSO REDUIRES THE APPLICANT FOF SUCH PERMIT TO FILE A SIGNED W
STATEMENf TMAT HE OR SHE IS LJCENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI-
� CENSE UW(CHAPTER Y(COMMENCiNO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSp3
FESSIONSCODE)ORTHATHEORSHEISEXEAIPTTHEREFROMANDTHEBASISFORTHEAILEGEDEXEMP- (�
TqN.ANYVIOLATqNOFSECTION7031.5BYANYAPPLICANTFORAPERMITSU&lECTSTHEAPPLICAN7T0 Z Re-Roof
� ACIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(f5oo).):
� OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial . -
WILL DO THE WORK,ANU THE STRUCTURE IS NOT INTENDED OR OFfEHEO FOR SALE(SEC.7os1,BU51- J
y NE55 AND PROFESSIONS CODE:7HE CAN7RACTOPS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPERiYWHOBUILD50RIMPROVESTHEREON,M1DVrtiODOESSUCHWORKHIMSELFORHERSELFOR m
Q THROUGH HIS OH HER OWN EM7LOYEES,PqOVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
� OFFEREDFORSALEIF,FIOWEVER7HEBUILDINGORIMPROVEMEHTISSOLDWRHINONEYEAROFCOMPIE-
Z �TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOH THE PUHPOSE OF SALE).
❑1,tiS OWNER OF hiE PROPERTY,AM EX0.USNE�V CAMRACTING WITH LICENSED CONTMCTORS
� TO CONSTRUCT THE PRQIECT(SEC.7011,BUSINESS AND PROFESSIONS CODE:THE CONiRACTORS LI- V0IU8IlOf1 � d� ADJ.AREA
W CENSEUWDOESHOTAPPLY70ANOWNEROFAPROPERTYWHOBUILDSORIMPROVES7HEREON,AND
� WhqCONTMCT5FOR5UCNFROJECTSWITHACONTRACTOR(5)IICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE �
� TORS LICENSE UW.).
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O ❑1 AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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DATE ONMER F'
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTY OF FERIUM THAT I AM LICENSED UNDER PROVISIONS Of CHAPTEH � '
� Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE.AND Z
��� MY LICENSE IS IN FULL FORCE AND EFFECT. m
0 LICENSE CLASS Ci/ � LIC.NQ ,��S�/� �
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBY AFFIRM UNDER PENALTY OF PERIURY ONE OF THE FOLLAWING DECLARATIONS:
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� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEN7 TO SELF-INSUPE FOR WORKERS' S
COAIPENSATION,AS PROVIDED BY SECTION 3700 OF 7HE UBOR CODE,FOR THE PERFORMANCE U
Q � OF THE WOHK FOR WHICH THIS PERMI7 IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION � /�
� Q � 370o OF THE LAHOR OODE.FOR THE PERFORA!ANCE OF THE WORK FOR WHICH THIS P[RMIT IS � \ u
. ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
j ' c,wRiEp PLAN REVIEW
� ' POLICYNUMBER ELECTRIC
� ,; (M1i65EC�lUNNE�NOTBE00MPlETEDOF71#PERMfISFORONEMNDRED00LLAAS(5100)ORLESS} PLUMBING
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Z ': I CERTIFY THA7 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
�} �. SHALL NOT EMPLOV ANY PERSON IN ANV MANNER 50 AS TO BECAME SUBJECT TO THE
N � WORKERS'COMPENSA710NUWSOFCALIFORNIA,ANDAGREETHA7IFISHOULDBECOME INSPECTIONFEE
� SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS Of SECTION 3700 OF THE UBOR �
O � CADE,I SHALL FORTHWITH COMPLV WITH TH��//PROVIS S. ISSUANCE r
p DATE:_ ���/ APPUCANT. � �, /� �SMIP
W ENERGY P/C
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
LL SU&IECTANEMPLOVERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOlURS(5700.000).IN PDDITION TO7HE COST OF COMPENSA710N,DAMAGES AS PHOVIDED FOR IN
J SECTION 37oe OF TIE UBOR CODE,MTEf1EST,AND ATiORNEY'S FEES. RETENTION FEE: .� �
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV _ �
a- FOR THE PERWRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.�. 1 _ ._ �-_-`_4 � .
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� LENDER'S NAME
F= LENDER'SADDRESS �..� �J�
� I CERTIFY THAT I HAVE READ 7HI5 APPLICATION AND STA7E THAT THE ABOVE INFORMATION IS CORRECL TOTAL FE ES - ty�J ,��„/
w I AGREE TO CAMPLY WITH ALL qTV AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
� CONSTRUCTION,AND HERE6Y AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE �7 n^ / �y{q /� //',/�
ZABOVE-MEHT� P. R7YFORINSPECTIONPURPOSES. COMMENIS Y%T�f'IJ��G/� "" l.� � 1l� . l_/�7.I'�'tiL'�
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m PERMITTEE AME(P IN7) � _� ��
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� SIGNATURE OF PERMITTEE DATE _
= RECPT.NO. PAID BY VALIDATION
~ WHITE--Depertment Copy,YELLOW�inance Capy,PINK—Assessor Copy,GOLDE�D--File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL FHA REC�MTS "
ELECTRIC GROUND UNDER FLOOR DUCT
GROUND PLUMBING UNDER FLOOR CUt�IdUIT i ___ _
SLAB GRADE FIREPLACE FOUNDATION ___
TEMP POWER � FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING, ' _ 8 FT. BOND BEAM _ __ _
FRAMINGNENTILIATIdN � FINAL BOND BEAM
RdOF COVFR � PRE-GRADWG
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUfVIBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATIOPI POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWAL.L iVAILING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK �ANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
G1�S AIR"fEST FINAL ZONING
FEti�4L�:UNST. FIRE DEPT. FINAL �i `
FiNt�L NEATING HEALTH DEPT. FINAL.
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