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. 1f� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES SCP 1 O ZOOZ
I 21660 E.Copley Drive Suite 190 PRE$$
(909)860-3195 Fax(909)861-3117 Q
�������W BUILDING PERMIT APPLICATION 7 � FIRMLY
JOBSITE APPLICATION �J PERMI f} /C �
o ADDRESS I°JI�} VALLE"Y V�ST/"t fl��V� DATE � v'I NUMBER � OV
$ ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER Gen.'rEl,�/�t`� GOi�� C�-7✓T��
" ADDRESS I�1''� Vd[.�y V�LTA Al�1�/E ZONING SETBACKS �
QCITY hloMon.//� 8,��. ZIP 9�'15 b TEL. FRONT RW ❑
� APPLICANT XL F�QE PKoTttcribU ca TEL.��`�)55N-L�3:2 REAR ❑
SIDE/SIDE STREET RW ❑
� CONTRACTOR XL ��e� ITRDT�G7�K>N CO. SIDE ❑
ADDRESS I� 5// .t/,�vT/L�/S R(VC ��
� cirv La���� 4(1WE ZIPS�y� TEL.714)55'�/-�0�� PROPOSEDUSE �/s�t= S%�/ZiA/��.L/QS '7�.I KLE��S
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a ADDRESS UNITS STOFIIES BEDROOMS
� CITY � ZIP TEL.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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� 1 HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8fdJ0/CefPOR
W CENSEUWFORTi1EFOLLOWINGREASON(SEC.7031.SBUSIHESSANOPROFESSIONSCODE:ANYCITVOR (�
U COUNTYWHIq1RC-0UIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W patio/Deck
w TURE,PRpR TO 1T9 ISSUANCE,AL50 REW IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO w
� STA7EMEHT 7HAT HE OH SHE IS 110ENSED PURSUANT TO 7HE PROVISIONS OF THE CONTMCTORS LI-
� CENSE UW(QIAPTER 0(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PHO- � PooVSpa
FESSqNS CODE)OR lYUT HE OR SHE IS EI(EMPT THEREFROM AND THE BASIS FOR hIE ALLEGED EXEMP-
TION.AHYVIOlAT10NOF5ECTION70.11.5BVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICAMTO Z Re-Roof
� F, A CML PENALTV OF NOT MORE 7NAN FNE HUNDRED DOLURS(i5oo).):
� ❑I,ASOWNEROFTHEPROPERT/,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 COrt1rt10fClel �
NALL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70a1,BUSI- J
NE55 M1D PROFESSIONS CODE:THE CONTMCTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
� PiqPERTYWFIOBURD50RIMPROVESTHEHEON,ANDWHODOESSUGiWORKHIMSELFORHERSELFOR � � ' . �
., Q iHROUGH MIS OR HER OWN EMPLOVEES,PROVIDED 7HAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m -
0 OFFEREDFORSALEIF,HOWEVER7MEBUILDINOORIMPROVEMENTISSOLDWITHINONEYEqROfCOMPLE-
Z ��TqN,THE OWNERAUIIDER VALL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
❑I,tiS ONMER OF 7HE PROPEHfY,AM EXCIUSIVELY CANTMCTINO WI7H LICENSED CONTMC70R5
Q TO CONSTRUCT hIE PRO,IEC7(SEC.7a1,9USINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81U811011 'iZ. ADJ.AREA
W CENSE LAW DOES NOTAPPLV TO AN ONMER OF A PROPERTY WF10 BUILDS OR IMPROVES THEHEON,AND
C-r- Nh1000NTMCTSFORSU�.HppQ1ECT5WITHACONTRAC70R(S)LICENSEDPURSUANT70THECONTRAG QUANTITY DESCRIPTION FEE
� r TORS 110ENSE UW.).
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� ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� DATE OWNER �
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F LICENSED CONTRACTORS DECLARATION W
� 1 HEREBV AFFIRM UNDER PENALTV OF PER1UFiY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTEP Ur
� 0(COMMENCINO WITH SECTION 7000)�OF DIVISION a OF THE BUSINESS AND PROFESSIONS CADE,AND Z
X NY IICENSE IS IN FULL FORCE AND EFFECT.
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� L�CENSE CLASS G��`(� LIC.NO. �' 1 1��I �
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� � WORKERS'COMPENSATION DECLARATION 3��` �
� I HEREBV AFFIRM UNDER PENALTV OF PE0.1UM ONE OFTHE FOLLOWING DECLARATIONS:
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� _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENT705E1F-INSUREFORWORNERS' 2 . .
COMPENSATION,AS PROVIDED BY SEC710N 370o OF THE UBOR CODE,FOR THE PERFORMANCE U
� Q OF THE WORK FOR NMICH 7HIS PERMIT IS ISSUED. �
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W J�I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSUfUNCE.AS REDUIRED BY SECTION �. � . /-��,r� '�( r' r I
Q 37ooOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICH7HI5PEHM1715 � � � �J���� /" (T"C � V a f
ISSUED.MY WORKERS'OOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION ,
jCAHRIER�.��ONT Go�PENSn.t-�on.� �f�IS, LD p�,qNREVIEW - � '
� POLICYNUMBERwnl9�JI��/bNy1d3 '� ELECTRIC
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� (fFiISSECfqNNE�NDT8E001�LETIDOF7HEPERAQTISFt7RONEMN�DREDDOLLAR5�ii6O1oA�Ess� PLUMBING
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Z I CEHTIFY THAT IN hiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI715155UED,t MECHANICAL �**�^fF n fs
(,7 SHALL NOT EMPIOV ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE qpQ�q�.]���'fj �}'l'�Y`�a �wa n�a
N WORKERS'COMPENSATKKJ UWS OF CALIFORNIAµD AOREE THAT IF 1 SHOULD BECOME INSPECTION FEE �.11..�i�.v --� s/`. � 'r t�
SUBJECT TO THE MfORKERS'COMPENSATIO ROVISIONS OF SECTION 3700 OF THE UBOR � P.14 ^��:�-�� ��= � '
s CODE,I SHALL OFiTHWITI COMPLY WI7H`T�'`�SE PROVI510�"� C ISSUANCE ����� `
� �f N�'.cry J� SMIP rc�l P Y P�°�}�:� Z��l�
p DATE: r` APRICANT. _�(,L ��V y .� . ,
� ENERGY P/C
J WARNINO:FAILURE TO SECURE W'ORKERS'CAMPENSA710N COVERAGE IS UNUWFUL,AND SHALL BE
LL SUBJECTAN EMPLOYER TO CRIMINAL PENAL7IES PND CIVIL FINES UP TO ONE HUNDRED 7HOUSAND ENERGY PERMIT -
DOLLARS(f100,000),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN .
� J SECTION 37oB OF hiE LABOR CODE,INTEREST,AND ATTORNEI"S FEES. RETENTION FEE: '
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� CONSTRUCTION LENDING AGENCY p -q T ���. �
� 1 HEREBV AFFIRM UNDER PENALTV OF PERIURY 7HA77HERE IS ACONS7RUCTION LENDING AGENCY
FOR THE VERFORMANCE OF iHE WORK FOR WHICH THIS PERMI715155UED(SEC.3ov7,CIV.C.�.
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� LENDER'S NAME
F- LENDER'SADDRESS
� ICERTIFYTHATIHAVEREADTHISAPPLI A710NAIJDSTATETHATTHEABOVEINFORMATIONISCAHRECT. TOTAL FEES �-
� I AGREE TO COMPLV WITH PLL CITV M1D COUN7Y ORDINANCES AND STA7E UWS REI,ATING TO BUILDING f 1 � �y�.�� , y
� CONSTRUCTION,AND HEREBV AUh10RIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON 7HE n_ 1 1
� ABOVE-MENTIONED PROPERTY FOR INSPEC7qN PURPOSES. j�JV�.°'v � �
COM�QENTS
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m• PE 7TEE NAME RI " �
c4i� S-I�-' � -
�' SKiNATURE OF V (TTEE OATE
_ _ RECPT.NO. PAID BY VALIDATION
~ HITE—Depertment Copy,YELLOW�inence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
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FTGS/FORMS/STEEL ' FHA REQMTS
ELECTRIG GROUND UNDER FLOOR DU 7, .._. .
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GROUND PLUMBING UNDER FLOOR CUhIDW17�:� � ��:�': r . , �1�. �- :�'��
SLABGRADE FIREPLACE.FOUNDATION � - �' =• ''" �'�'"�' ""'
TEMP POWER FIREPLACEJBO(V�BEAM � � � ' �
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WATER SERVICE MID HT. BOND BEAM` :`;. .;:,'
ROOF SHEATHING - - ' - ��M ' � •
8 FL BaND:B ,;�.; ,� � ��•-�,�:.,; �,�_ :.,..�
FRAMINGNENTILIATION FINAL BOND B��KM
ROOF COVER PRE-GRADING �,�'�•, �:,�. �
ROUGH HEATING BENCHING
ROUGH ELEGTRIC ROUGH GRADING
ROUGH PLUfV1BING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXI: LATH/SIDING POOL FENCING
WALL INSULATION POO�FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING s � S DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. • � � �ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL C .fJST. FIRE DEPT. FINAL ,�
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBIMG ENERGY
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