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� � CITY OF DIAMOND BAR
COMMUNTI'Y DEVELOPMENT DEPARTMENT
_ 21660 E.Copley Drive Suite 190 PRESS
N (909)860-3195 Fax(909)861-3117
"""'� BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE APPLICATION tQ ��� RMIT P/C r�/
o ADDRESS 2859 WATER COURSE DRIVE DATE MBER #
c� ISSUE TYPE OCC
� APN LOT F/C� TRACT 47$�Q DATE CONST. GROUP
°C OWNER Diamond Bar West. LLC '�
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" ADDRESS 3�+8� Torrance B�Vd_ Stii te 3nn ZONING SETBACKS
Z CITY Torrance ZIP AnSn� TEL._�1(1-54(1-"�9 � REOART RW ❑
o APPLICANT Ri charrl Grnil rl TEL. Sg�e SIDEJSIDE STREET RW ❑
� CONTRACTOR .TCC COnStruCtlOIl SIDE ❑
� ADDRESS same 3S OWrier PROPOSED USE�12W 5111 10 Famil R0R1de1.Ce
CITY ZIP TEL. � �
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z DESIGNER R. Gould & AGsnr_ NO.DWEL. NO. NO.
a ADDRESS SII12 SS owner UNITS 1
� CI'IY ZIP TEL. STORIES 2 BEDROOMS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BI;ILDER DECLARATION SFWADD/REM
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U CWNTYWHICHREOUIFESA7ERMITTOCONSTRUCT,ALTER.IMPROVE,OEMOLISH.ORHEPAIRANYSTRUC�
w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES 7HE APPUCANT FOR SUCH PERMIT 70 FILE A SIGNED w P8t10/DBCk
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO hIE PROVISIONS OF THE CONTRACTOR$ll-
� CENSE LAW(CNAPTER e(COMMENCINO WITH SECTION]0oa)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
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� TION.ANV VIOLATION OF SECTION 7031.5 9V ANV APPUCANT fOH A PEFMIT SUBJECTS THE APPLICNfT T0 Z RaRoof .
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f600).):
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Z Wlll DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7w�,BUSI- J
� NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV TO A1J OWNER OF � p o r ch � ' 3 �
PROPERTVWHOBUILDSOi11MPROVESTHERE-0N,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR �'1�O '+• +
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Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE OID NOT BUIfD OR
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w � ❑I,AS OWNER OF THE PROPERTV.AM E%CLUSNELY CONTRACTING WfTH LICENSED CONTMCTORS
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W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER � ry 0 •
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X AIV LICENSE IS IN FULI FORCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION Q
N I HEREBY AFFIi7M UNDER PENALTV OF PERIUFV ONE OF THE FOLLOWINO DECLARATIONS: Z .
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� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORNERS' ''_� � ' •' U � � � ... ..^ + � ,�
� COMPENSATION,AS PqOVIDED BV SECTION 3700 OF THE LABOR CODE.FOR 7HE PERF-0RMANCE U
Q OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED. , �
Qw X IHAyEANDWILLMAINTPJNWORKERS'.COMPENSATIONINSUR/WCE,ASREOUIREDBVSECTION
37000F THE LABOR�CODE,FOR THE PERf-0RMANCE OF THE WORK FOH WHICH iH15 PERMIT IS a � � ' /� M
� ISSUED:,MYWORKERS'COMPENSATION,INSUR/WCECARRIERANDPOLICYNUMBERARE:�,j � '�� ,CONSTRUCTION� � F. ��.��• ����,�� � ' ' �Vh�OIG"v
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Z POLICV NUMBER W 9 g B 1�4�S n 4 ELECTRIC � � p-
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED,I MECHANICAL �VD• L J V
CJ SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE -
Uj wORKERS'COMPENSA7IONLqW50FCALIFORNI0.ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE� �
SU&IECTTO THE YlORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR
� CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE Y
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p DATE: � APPLICANT: SMIP
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J WARNIMO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C -
�y SU&IECTAN EMPLOYER TO CqIMINAL PENALTIES AND CNIL FINES UP TOONE HUNDRED TF/OUSAND !
DOLLARS(S1ao,o00),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAOESASPFOVIDEDFOHIN ENERGYPERMIT
J SECTION 3708 OF THE LABOR COOE,INTEREST,AND ATTORNEV'S FEES. • , ' y
OC � RETENTION FEE:
� O CONSTRUCTION LENDING AGENCY ' PRE-ALT F �
� I HEREBV AFFIRM UNOER PENALTV OF PERJURY THATTHERE IS A CANSTRUCTION IENDINO AGENCY
FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEDlSEC:30Y7,CIV.C.�. .
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� LENDER'S NAME
H LENDER'SADDRESS �
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w I CEflTIFV iHAT I HAVE READ THIS APPLICATION ANO STATE THAT iHE ABOVE INFORMATION IS CORRECT. TOTAL FE� � / �
� I AGfiEE TO COMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING /� � `��7
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF 7HI5 COUNTV TO ENTER UPON THE � �/'. �j.��' {„/(/ ,, _ Q� _I. _
Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. C MME TS �Y � N r�••i �w`/�
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N sic REOFPERMITfEE o�rE RECPT.NO. PAID BY VALIDATION
� WHITE—Depflrtment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
CiTY OF DIi411A��D ��R : . . �"
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SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE ' MID HT. BOND BEAM
RaOF SHEATHING 'Z O� .�,�, 8 FT. BOND BEAM •
FRAMINGNENTILIATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
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SHOWERlTUB TEST POOL ELECTRIG '
EXL LATH/SIDING 6� Z.� b� POOL FENCING ' �
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CEILING INSULATION -W OFF SITE IMPS. '(
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SEWER FINAL ENG. � � ���
SEPTIC TANK � � ' LANDSCAPEIIRRIG. �
SEEP PIT/L.L. ON SITE IMPS. _
GAS AIR TEST FINAL ZONING
FINAL CONST. ( p �l FIRE DEPT. FINAL
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FINAL ELECTRIC DEV. FEES PAID
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