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�'�` � DEPARTM[ENT OF COMMUNTI'Y&.�DEVELOPMENT SERVICES
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21825 E.Copley Drive
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY it'DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
5-t•31i
PRESS FIRM�Y
JOBS ITE
ADDRESS
.31192_witi i)MTIi,_DRIVF
APN LOT ii TRACT 4R4R7
OWNER Windmili Estates,��C
mmeEss 3480 Torrance Blvd.Ste.300
CITY Torrance ZIP 90503TEL310-540-399
APP�ICANT Richard Gould TEL.Same
CONTRACTOR JCC Construction
ADDRESS same as owner
CITY ZIP TE�.
ARCH/ENG/
DESIGNER R.Gouid&Associates,Inc.
ADDRESS same as owner
CITY ZIP TEL.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOL�OWING REASON(SEC 7031 6 BUSINESS AND PROFESSIONS CODE ANY Ore OR
COUNTY WHICH REQUIRES A PERMITI'0 CONSTRUCT,A�TER,IMPROVE, DEMOLISH.OR REPAIRANY STRUG
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE t.AW(CHAPTERS(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS CHF APP�ICANT TO
A CIVI�PENA�TY OF NOT MORE THAN FIVE HUNDRED DO�LARS($500))
DI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES ASH-WIN SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY INHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE),
0 I,AS OWNER OF THE PROPERTY.AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRP,CTORS
TO CONSTRUCT THE PROJECT(SEC 7004, BUSINESS AND PROFESSIONS CODE THE CONTRP,CTORS LI-
CENSE�AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO aulos OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORIS)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE�AW)
0 I AM EXEMPT UNDER sec B 8 PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEClr4RATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION SOP THE BUSINESS AND PPOFESsONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICENSE CLASS B LIG NO 671982
DATE CONTRACTOR 0 k.,C Cons t.
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t.ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
'NT
I A
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IJ�BOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED,My WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER State Compensation insurance Func
! POLICY NUMBER 160449700
(THIS SECTION NEED NOT BE COMPLETEDOETHE PERMIT IS FORONE HUNDRED DO��ARS(8100)OR�ESS)
i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
.7 SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
)
DATE APP�ICANT
)
J
1 WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFU�,AND SHAL�BE
- SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
.l. SECTION 3708 OF THE LABOR CODE,INTEREST.AND ATfORNEY'S FEES
3 CONSTRUCTION LENDING AGENCY
- I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE is A CONSTRUCTION �ENDING AGENCY
,-, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C)
3
LENDER'S NAME
- LENDER'S ADDRESS
g.:
C I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
u
, I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUI�DING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
-. ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
7-
5
-t
D
'CI PER NAME(PRINT) ........,
f) SIGNATURE OF PERMITi"EE DATE
f
APP�ICATION
DATE
k.).. dfr),...,PERMITRH M
NUMBE PIC oa 3ac
ISSUE
DATE
1 elA%,0 O.-L"...C OPNE OCC
S T GROUP
FRONT SETBACKS
REAR
ZONING SIDE/SIDE
SIDE
RW EI
EI
STREET RW P
E
N0. PROPOSED
UNITS
USE New Single Family Residence
DWEL.,
1
wj attached garage
N0. N0.
STORIES @ 2 BEDROOMS 5
DESCRIPTION SQ. FI'. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM i,.i ^ .,6 0
W GarageJCarport IIIIMMIIIIIIIIIL 1
UJ Patio/Deck
W
LI-
0
z
5 PooUSpa
_•�/
5
03
Re-Roof
Commercial
Porch 125 .5
ti-b
Balcony 264 .... 1.9 c4
Valuation $�/a cAVO.iftkDJ AREA
QUANTITY DESCRIPTION FEE
-J
<
C)
E
H
0
Lil
-J
Ll.l
0
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a
2
D
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0-
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0
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0
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2
CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
MECHANICAL
INS2ECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENERGY PERMIT
RETENTION FEE
PRE-ALT FE -11711,eie'
';,s 5
III
e ,
. i
ii•
. dibant
e
1
10. n
• - A \
A
• ITN
TOTAL 0 044
COMMENTS FE5S_A 111-q- 11
AoiLO J--1 i
1,1PAID
RECPT NO. BY VALIDATION
WHITE—Department Copy.Y mance eopy, Pt1NR—PSSeSSoi �Iopy, ,
ke-5,409e5:77-e
.0 kik
4-6 tiS ACif.,,43-03 p4.4
eft h
&ratio /4,
7-/V-os p/,4?
� �
PRESS FIRM�Y
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE*.I. 0 q g
ADDRESS J WlyNcl,vkli II Dri ve
APN LOT TRACT q_q_7_,
. , .q_s
OWNER IV(Ad Iva I n S 0 vi-e.S .--(-'
I
ADDRESS 311g0 Tot-v4'cc g i v .
CIl'Y'Tor rei. i,c e. ZIP eloblik3 TEL. lie-5110-3'140
APP�ICANT grin.-vs A-v.94 i'vs TEL.
CONTRACTOR I C C eei if,4.;ry c 4.'
ADDRESS'Stitt) .r.,,,-,,,....,e B ivd,
CITY TO,f'if-et"re. ,e-
ZIP ciair TEL, i i0-9fic---:)kt
ARCHJENG/„
DESIGNER INIngeKvAte-ASt--,r -
ADDRESSa3C)r 14- i.ie pc IN i.e.i 6., 13 40 SO).5
CITY TC4'),:ti..,c A. ZIP Ci V 505 TE�.-310- 176-0$3,
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PER]URY THAT IAN EXEMPT FROM THE CONTRACTORS LI-
CENSE I.AW FOR THE FO��OWING REASON(SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE IAW(CHAPTERS(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS f HE APP�ICANT TO
A CIVI�PENAI.TY OF NOT MORE THAN FIVE HUNDRED DO�LARS(SOW))
DI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUII.DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE),
0 I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE�AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAG
TORS�ICENSE tAW)
0 I AM EXEMPT UNDER SE.O B EEC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
At .. .7 A.l
LICENSE CLASS LIC NO b f 1 9 2 2-
DATE CONTRA,CTOR T CC (c.,".. 51f 1,42 hie,
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FOLLOWING DEC�ARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKTS'.COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
,_ �� �� .....
CARRIER ..0 ate. 0 e^iJ4 iCt( A c ti IY l,l
POLICY NUMBER i r,0 41 ii t 70r,
(THIS SECTON NEED NOT BE COMPLETEDOFTHE PERMIT IS FOR ONE HUNDRED COU_ARS(51C0)OR�ESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB]ECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE tABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE APPLICANT,
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFU�.AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLI�,RS($100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C}
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY'THAT I HAVE READ THIS APPLICATION AND STATE'THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
PE MITi'EE NAME(PRhT)
neY
SIGNATURE OF PERMII�f'EE DATE
APPI.ICATION
DATE
1 1 143 1 oi. PERMIT
UMBER GIItA PIC 03-015
#
ISSUE
DATE
\--(')— PE OCC
ONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE
USE RW 0
0
SIDEJSIDE STREET RW 0
EI
PROPOSED
N0. Ail
UNITS Mia lMINAMIINGIN .
DWE�,
NO N0,
STORIES BEDROOMS
cn
I-u
L�I DES^PTION FACTOR PSF
U-
0
Z AD).AftEANALUATION
SFR/WI qREM 0/7. 5c 00.10
Garage/Carport
Patio/Deck
PooVSpa
Re-Root
(-5
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5
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Valuation AD7 AREA
QUANTITY DESCRIPTION FEE
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TOTAL FEES i ql)0.-- 7g 5 0
COTENTS
a
inr-yr al,----I FIr3-57'.
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RECPT NO PAID BY i 0 VALIDATION '
WHITE—Department Copy,YE�LOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
a to.—
0
• S,;• /o,..; .
. .
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
ON
JOBSITE
ADDRESS'3 0 el g ta,telim tt{
APN LOT d-ig/e'I
OWNER L i irk t..Oli glre-r 4
S LL.C.
ADDRESS OR 4KE'ti
CITY ZI 0 TEL. I
APP�ICANT TEL.
CONTRACTOR ZS�'3 E
ADDRE.p pis 14 , C.l .
CITY c.)COi4 Vivets, ZIP'fal_3_TEL 2ic-Ii#r31'
ARCHJENG/
DESIGNER - ... J 4; X.
ADDRESS:._877Y.:F1,12ailleMtp-
crry-ro-P.41'c: ' ZIP91,93, TEL.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FO��OWING REASON(SEC 7031 5 BUSINESSAND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI.
CENSE t_AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION SOP THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVI�PENAL.TY OF NOT MORE THAN FIVE HUNDRED DO�LARS($500)):
0 1_AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITHWAGES AS THEIR SO�E COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SO�D WITHIN ONEYEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SA�E)
DI,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT
THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI-
CENSE IAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE�AW)
0 I AM EXEMPT UNDER SEC. B. &PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEClr4RATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM�ICENSED UNDER PROVISIONS or CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
LIC NO.tilIzzz
LICENSE CLAT ...- t
DATE 6)i 3 c CONTRACTOR 3-.l^15 CiS-4414 4-
WORKERS'COMPENSATION DECLARA,TION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
(0.".<1...-IAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS'••&11SAe.TION INS CE CAR IER AND POLICY NUMBER ARE.
CARRIER rA
POLICY NUMBER �.7%if;XligrnS dt,grir
(THIS SECTION NEED NOT BE COMP�ETED OF THE PERMIT IS FORONE HUNDREDDOLLARS MOO)OR�ESS).
(CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE. APP�ICANT
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFU�,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE�P,BOR CODE,INTEREST,AND Al�'ORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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ENERGY PERMIT
RETENTION FEE.
PRE-ALT FEE:
,(^,h
,,. ....)14
TOTAL FEES ""taritt
COMMENTS
RECPT. NO. PAID BY ....)...,
VA�IDATION CS.
WHITE—Department Copy, 'YE�LOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
T l.);A.,11:1-,:',g3 31-7%4-1 f--ft.7(°.-r
; UNDER IOOrt
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;
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SEE:
PRESS
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING ATI
JOBSITE
ADDRESS 3 4161R-4j t.2tro-Inir v4/...41--vtlJ I i
APN LOT j0 TRACT 40(0,
OWNER al li NJ
ADDRESS ols-tA).- I vd. mot/
e. ,TEL
{4171*...4,_RS z7,60i�r.
CITYAPPLICANT
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CONTRACTORilcle--
41Ai bV.C.
ADDRESS j I6ela "re-50"
CIl'Y I.wit ZIP WI TEL. 16401-44 412"
ARCH/ENG/
DESIGNER O.C-efia'MA3
ADDRESS Ifo,^%-- ehrea.c...A ri<,-.
CITY leirja...- ZIP Utteu'1ELp9
r,,,, kl—_jz0
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�AW FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMOUSH2OR REPAIRANY STRUG
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE�P,W(CHAPTERS(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A��EGED EXEMP-
TION.ANY VIOtATION OF SECTION 7031.5 BY AAP/APP�ICANT FORA PERMIT SUBJECTS THE APP�ICANT TO
A CIVI�PENA�TY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5600).):
0 1,AS OWNER OF THE PROPERTy,OR MY EMPLOYEES WITHWAGES AS THEIR SO�E COMPENSATPON,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COIAPLE.
SON,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FoR SUCH PROJECTS WITH A CONTRACTOR(S)�ICENSED PURSUANT TO THE CONTRAG
TORS UCENSE LAW l.
CI I AM EXEMPT UNDER SEC. B LI P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT t Am�ICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS 0040 PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
UCENSE CLASS 13.c.--)J.c..-..0 LIC. NO, 403/(4)
DATE 0,-tr- 19 CONTRACTOR 44 c,IA4,1 ,t_t....
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t.ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
)1„ I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
• 3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER Staft- i-lA.ti
POLICY NUMBER aip—h 3
(THISSECTION NEED NOT BE COMPLETED OFTHE FE IT IS FORME HUNDRED DOL�ARS($100)OR LESS).
I CERTIFY THAT IN R4E PERFORMANCE OF THE WORK FOR WHICH THIS PERMITS ISSUED. I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE(ABOR
CODE.I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE. (14- ...13--.123APP�ICANT: R4)4rEvt YA71,
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU�, SHA�L BE
SUEUECT AN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLIARS(8100.000),IN ADDMON TO THE COST OF CO)APENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 370 OF THE LABOR CODE,INTEREST,AND ATfORNEYS FEES,
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEG 3097,CIV. C.).
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE LAWS RE�ATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON 114E
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
I9 17 Ilk. )//o-XI,
PERMIITEE NAME(PRINT) p
. p--a--0 3
SIGNATURE OF PERMITME i/....
DATE
APP�ICATION
DATE
PERMIT
Q
R ,
NUMBE :)..A....3 4ip/b .,.m.t.
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
0
SIDEJSIDE STREET RW EI
0
PROPOSED
N0,
UNITS
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STORIES BEDROOMS
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LU DESCRIPTION SQ. FI'. FACTOR PSF ADJ.AREANA�UATION
U-
0
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SFFI/ADD/REM
Garage/Carport
Patio/Deck
Pool/Spa
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a
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015
Stilv l.-09
Valuation 9,71n9 ADIAREA
QUANTITY DESCRIPTION FEE
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RETENTION FEE:
PRE-ALT FEE: I C.It<7, 1-<:1
• 3J a . 19"c e-1
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.'---C2:.
•+ (VG/
TOTAL FEES i 3-q-, 10
COMMENTS
RECPT. NO. j/.--' •(-(5-- PAID BY 8 8-22.... VALIDATION
WHITE—Deplment Copy,YE�LOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
e CITY OF DIAMOND BAR INSPECTION RECORD
;, -;�4,;;• ; • .
• ct
FTGSIFORMS/STEE_ :.,,lY .4.........-A----- ;I FHA REQMTS !
LECTRIC GROUNDS I : UNDER F�OOR DUCT
GROUND P�UMBING ; UNDER FLOOR CONDUIT
S�P,B GRADE.: ; FIREP�ACE FOUNDATION
t
TEMP POWER ' ; FIREP�P,CE BOND BEAM
WATER SERVICE ! . MID HT. BOND BEAM
i - - - - - ------
ROOF SHEATHING : •8 FT. BOND BEAM
FRAMING/VENTILATION . i 'FINAL BOND BEAM
ROOF COVER . : PRE-GRADING
ROUGH HEATING , I; BENCHING
ROUGH E�ECTRIC . ! ! ROUGH GRADING •
ROUGH P�UMBING 1 I FINISH GRADING .
, I : P00�ELECTRIC
SHOWER/TUB TEST .
EXT. LATH/SIDING . I I POOL FENCING
, r
1 ,
WAL�INSULATION '•POOL FINAL
1 I
CEI�ING INSU�ATION , 1 !OFF SITE IMPS. •
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SEWER , � 1, FINAL ENG.
SEPTIC TANK-- - --- �ANDSCAPE/IR/RIG.
SEEP PIT/L�. '
GAS AIR TEST
1 I
i I ON SITE IMPS.
i 'FINAL ZONING
-/24.1 I I FIRE DEPT. FINAL
FINAL CONST, ! ,
i HEALTH DEPT. FINAL
vi:
FINA�HEATING ,
FINA E�ECTRIC Sf I Miff 1 1 DEV, FEES PAID
FINAL P�UMBING 1 ENERGY
I
- „ 1
' Ll„4 .-: i=. :',I"'!'Iti I :), -
COMMENTS
SEEP SEPTIC PIT/U TANK SIZE
, , SIZE
v
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�—'——— '—
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WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-F�le opy, App cant s Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APP�ICATION
JOBSITE
ADDRESS 3 Oc 1 gioil wth.... 1 ii vft
APN LOT 8 TRACT itg-teRi
OWNER CHYAJ cfriox)
ADDRESS 3 vy g-WI v^ii KM I PP-
CITY cit Alt. 1 Bair ZIP ei 1 iftr TE�.
APP�ICANT.1%04112,_44447 TEL.04_}_t_iip_474(
CONTRACTOR Ali.
ADDRESS Miliiturt I, ..',..
CITY t 1404:t.Ar ZIP L.f• rfa
ARCHJEOG/ qi Iii
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOL�OWING REASON(SEC 7031 5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMO�ISH.OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE�AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 By ANY APPLICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500).)-
DI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�AW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E-
TION.THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
DI,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7544, BUSINESS AND PROFESSIONS cope THE CONTRACTORS LI-
CENSE(AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS�ICENSE�AW).
0 I AM EXEMPT UNDER SEC B&PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECIJ�RATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT,
V
LICENSE CLASS 13 t---Yr)C'3�iC NO ay 3 q
DATE (3"'-i,t-?-0 5 CONTRACTOR 44c,
WORKERS'COMPENSATION DECLARA,TION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARA,TIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
37013 OF THE�P,BOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER
POLICY NUMBER
(NS SECRON NEED NOT BE COMFLETED OF THE PERMIT IS FOR ONE HUNDRED DO�LARS(S1C0)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
• SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE: APPLICANT.
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
i SECTION 3709 OF THE LABOR CODE,INTEREST.AND ATfORNEYS FEES.
CONSTRUCTION LENDING AGENCY
i
. I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCT/ON LENDING AGENCY
' FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097.CIV C).
. LENDER'S NAME
• LENDER'S ADDRESS
i I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
• I AGREE To COMP�Y WITH A�L CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUI�DING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
1 ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
I
1
5 Pro 441c Y6706)
1 PERMIITEE NAME(PRINT)
) .l_....AO b��� 1 *���
) SIGNATURE OF PERMII-fEE
. I I DATE
APP�ICATION
DATE
PERMIT:1_,P/
NUMBER"L'4R-# bB
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
EI
N0. PROPOSED
UNITS
USE
DWE�. pv.l)--- beet,
N0. N0.
STORIES BEDROOMS
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II I
Li, DESCRIPTION FACTOR PSF
u-
0
Z SQ. FI'. ADJ.AREA/VALUATION
SFR/ADD/REM
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Patio/Deck
PooVSpa
Re-Roof
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5
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Valuation I trirP AD).AREA
QUANTITY DESCRIPTION FEE
721
0
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0
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ISSUANCE
SMIP
ENERGY PJC
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE: (r.--5 C::O t'O'.
-:5-7—;----AtC)
CYZ9 �?
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TOTAL " 5�z,
COMMENTS FEES 7.s.
RECPT. NO. j/6 6-Th PAID BY_i5 ""2.-2- VA�IDATION �el/ii
DIAMOND BAR i
4k0,'
PRESS
FIR
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FINA�F=NAL H
NAL ELECT"'. P�UMBING
SET BACK
I Ef GSIFORMS/S1 EEL ELECTRIC GROUND
POUND PLUMBING
B GRADE
TEMP POWER WATER SERVICE HOOF SHFATHIr'r FRAMINGIVENTIt ROOF COVER 7>,O1:GH HEATIN RJURH P�CTRC
ROUT
=E.R.T" 'b"!
ATHIS;DINrs:A�L INSULATION AT10N
1 :PI IC"ANK":,!',!11111,"
-HA RE01
UNDER F�OOR-"CT UNIEn F OOF'
FIF;Er ACE P'�,lUNDATION
!REP�P,CE BOND BEAM
F ROL�.)[31:AN,'FINN Pf-,;,.;1)
lE-GH,", D INC;
,LYNGHING
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PA:D LN l.A Gv
SEETLUS7F
PRESS FIRM�Y
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
ON
BUILDING PERMIT APPLICAT
JOBSITE
ADDRESS;VI 8- Ww,a-N^ ii b(7.-
APN LOT 8- TRACT 45-1W7
OWNER ed:IWD/t)
ADDRESS 3127 V" 14.411 Intik it,8t,
CITY cit?Aw,,,,-,.. sae ZIP.1.iJ14,FTE�.
APPLICANT VZ...6).wk TEi..(jiy- Vie
y4.1
CONTRACTOR Aril e. (2.4;t
ADDRESS 316pi1 Too.,
CITY v�hau-t-i ZIP 4044 TEiftegroke
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE�AW FOR THE FO�LOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
CCUNTY WHICH REQUIRESA PERMIT TO CONSTRUCTA�TER,IMPROVE. DEMO�ISH.OR REPAIRANY STRUC-
TURE, PR/OR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE�P,W(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESS/ORS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A��EGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUB]ECTS THE APPUCANT TO
A avit. PENALTY OF NOT MORE THAN FIVE HUNDRED DO�LARS($900).):
0�AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITHWAGESAS THEIR SO�E COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,SUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE�AW DOES NOT APPLY TO ANI OWNER OF
PROPERTY WHO BUII.DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVEFL THE BUILDING OR 94PROVEMENT IS SOLD WITHIN ONE YEAFLOF COMPLE-
TION,THE OWNER-BUI�DER WU. HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I,AS OWNER OF THE PROPERTY.AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U-
CENSE t_AW DOES NOT APPLY TOAN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE�AW)
DI AM EXEMPT UNDER SEC 5.0 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT IAN LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MY UCENSE IS IN FU�L FORCE AND EFFECT.
LICENSE CtASS 8,6- 1 l,(-143 tic. NO. t 0 et;•
DATE 1 ,.-I v---n 3 CONTRACTOR / C.-- 14,012.1---
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS:
WI�L MAINTAIN A CF-RTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
I HAVE AND
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
K I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IJaBOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER iS-I-a44, fi.ta
POLICY NUMBER Tv-b 3
• (THLS SECTION NEED NOT BE CCMP�ETED OFTHE PERMIT IS FOR ONE HUNDRED DCUARS($100)OR�ESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SOAR TO BECOME SUBJECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
. SUBJECT TO THE WORKERS COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: (1-/S".-0 3 APP�ICANT: R.,:,471.K.. you
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOL�ARS(EI 00,000),IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE I�,BOR CODE,INTEREST.AND ATfORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
i
AGENCY
. I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING
• FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.).
I.1
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
- I AGF�EE TO COMPLY WITH A�L crry AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
VA)6,znik Y4-A)
PERMIITEE NAME(PRINT)
) ).-/s---0
3
111.......1
- SIGNATURE OF PERMITi'EE EFAITE
2
' --•---- - -
APP�ICATION
DATE
PERMIT- P/C -
NUMBER #c=t-.3•5-9,c,
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
0
SIDEJSIDE STREET RW 0
0
N0. PROPOSED
UNITS
USE
DWE�. 4611 1,-"F 12,7-FA,c{
N0. N0.
STORIES BEDROOMS
U)
11 1
l.l.l
LI-
0 DESCRIPTION SQ. Ff. FACTOR PSF ADJ.AREANA�UATION
Z
3
—I
5
CO
SFR/ADD/REM
GarageJCarport
Patio/Deck
Poo)/Spa
Re-Roof
Commercial
aim �-7- 12-Z"Fe.Ae
SOCO
Valuation_Init=5/4=2., ADIAREA
QUANTITY DESCRIPTION FEE
0
EE
l.-
0
w
-I
w
0
z
BE
2
n
a.
-J
a
0
2
a
x
O
W
2
CONSTRUCTION
PLAN REVIEW
ELECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
-7 4. . i -,. ?el .
O,S-
1 512)
TOTAL FEES il a .9--.z,
COMMENTS
.."1/11
RECPT. NO. li ... '6--S PAID BY1.1211-;)„_VA�IDATION
rtmBVit Copy. mance UOP, — , ,
fJc
CITY OF DIAMOND BAR INSPECTION RECORD
''1"r";"•.44:t...
I
,., . . . . ..
FTGSJFOR MS/STEEL * : i FHA RUNTS
E�ECTRIC GROUND . - , ; : UNDER FLOOR DUCT 1
GROUND PLUMB-1NG- . ; ' ; UNDER FLOOR CONDUIT
.. ', REPLACE FOUNDATION
SI.AB GRADE FI
--- - i 1 FIREP�ACE BOND BEAM
TEMP POWER ! 'MID HT BOND BEAM
WATER SERVICE
ROOF SHEATHING : 18 FT BOND BEAM
FRAMINGNENTI�P,TION 1 !FINAL BOND BEAM . .
; PRE-GRADING
ROOFCOVER ,
ROUGH HEATING ; ; BENCHING
ROUGH ELECTRIC ! ; ROUGH GRADING
ROUGH P�UMBING • . : ; FINIS GRADING
SHOWER/TUB TEST - ; !POOL ELECTRIC
EXT. LATH/SIDING ; I POOL FENCING ..
WAL�INSULATION i I ---i
1 I POOL FINAL 1
CEI�ING INSU�P,TION * !i OFF SITE IMPS.
DRYWAL�NAI�ING : ' DEDICATIONS
SEWER ! 'FINAL ENG.
SEPTIC TANK_ 1 ,
SEEP P-1-T/L.�. !LANDSCAPE/RMS.
GAS AIR TEST 1 ON SITE IMPS. -,-
I;FINAL ZONING 1
---i-
1
'/ i .i ,
FINA�CONST to' I I FIRE DEPT. FINAL
FINA�HEATING 1 ; HEA�1H DEPT. F:NAL
FINAL E�ECT RIC , ; ^ DEV,FEES PAID
FINAL P�UMBING � ;i ENERGY
. i -
. I .
' 1111,:;: '. :, ...A",.,:1..6-a-zi•-v- --i°'• ::'
COMMENTS
SEPTIC TANK SIZE
SEEP PITlU SIZE .
, 4-.., •.1"i ... :,, ;W-
'• - - ,..v.,
� � _ �
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copiey Drive
(909)860-3195 Fax(909)861-31ll PRESS
FIRM�Y
PERMIT - P/C
NUMBER #03 5(409
TYPE OCC
CONST. GROUP
FRONT SETBACKS RW
ZONING REAR
SIDE 0
CI
SIDEJSIDE STREET RW 0
0
N0. PROPOSED
UNITS
USE
DWE�. a>iac:.tc..--Ick_ss.c.. ....,,-k 1 x•••••-\--
N0. N0.
STORIES BEDROOMS
DESCRIPTION S0. Ff. FACTOR PSF ADJ.AREANA�UATION
co
w
W
U-
0 SFR/ADD/REM
z
15
5
m
GarageJCarport
Patio/Deck
Pool/Spa
Re-Roof
Commercial
Valuation S, -)417)0 ADIAREA
QUANTITY DESCRIPTION FEE
C.)
Er-
I-
C...)
Lu
-.I
tu
(�
Z
E5
2
n
-J
a.
{3-1—a S(1,rl4.11-
a
G)
2
<
x
C.)
io
2
CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENERGY PERMIT
RETENTION FEE: C?-0
PRE-ALT FEE: S; 3
5 ,G)c)Pck
I5
TOTAL FEES 9•
COMMENTS
paen, ,—„
PAID BY VAUDATION
RECPT. NO.
BUILDING PERMIT APPLICAT
JOBSITE
ADDRESS 3 D7 8.-IA,,A. Irv,;(k_ P R.—
APN LOT Ci" TRACT Lt 5?-4.,gli
OWNER CM IV pi VA/
ADDRESS
CITYoko...44, i....i- Rep( ZIP q i qs-TE�.
APPLICANT 144:)..I_$47a7_TE�701144240
CONTRACTOR It*t Le.% 1 4 41....
ADDRESS3,,,,,4: 7,..4
pis._
ZIP
CITY )IL...t TELg_o_Vja:4_—}.-fit
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT I MI EXEMPT FROM THE CONTRACTORS LI-
CENSE�P,W FOR THE FO�LOWING REASON (SEC. 7031.5 BUSINESS AND pROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCI',ALTER IMPROVE,DEMOLISH,OF%REPAIR ANY STRUC-
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE t.AW(CHAPTERS(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXE�IPT THEREFROM AND THE OASIS FOR THE A�LEGED EXEMP-
DON.ANY VIOtATION OF SECTION 7031.5 BY ANYAPP�ICANT FORA PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS($604):
0 L AS OWNER oF THE PROPERTY. OR My EMP�oYEES WITHWAGESAS THEIR SOLE COMPENSATION.
WI�L DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7594, BUS)-
NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E.
TION.THE OWNERBUI�DER WILL HAVE THE BURDEN OF PROVING THAT HE OR am DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE),
0 I.AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRP,CTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U-
CENSE t_AW DOES NOT APP�Y To AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTSWITH A cONTRAcToR(S)LICENSED PURSUANT TOTHECONTRAC.
TORS�ICENSE IJ�W.)
0 I AM EXEMPT UNDER SEC B a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECIJ�RATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT IAN LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 70(0)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE 15 04 FU��FORCE AND EFFECT.
UCENSE CLASS g i c..--il.,0-3�IC N0. k6n h
DATE ---(7) CONTRACTOR if c LOAIi St---'
--.4.--�tr'..
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY ONE OF THE FO�LOWING DECLARA,TIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT 70 SELF-INSURE FOR WORKERS'
COMPENSATION.AS P ROMPED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I( I HAVE AND WILL MAINTAIN WORKERS*COMPENSATION INSURANCE.AS REQUIRED BY SECTION
3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION I URANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER il-nft et.4.
POLICY NUMBER . .-yce.--0 3
- (T)SSECTION NEEDNOTSECOMPLErEDOF THE FERMI IS FOR CND-MORS)CcuAils($100)OR�ES%
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITS ISSUED. I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE lABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: ().-1 3-b 3 APP�ICANT:
i
I WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU AND SHA��BE
. SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOU.ARS($100.0311),IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROMDED FOR IN
I SECTION 3700 OF THE LABOR CoDE,INTEREST.AND A'rf'ORNEY'S FEES.
i CONSTRUCTION LENDING AGENCY
i AGENCY
- I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING
- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097. CIV. C.).
i
LENDER'S NAME
LENDERS ADDRESS
; I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATED-LAT THE ABOVE INFORMATION IS CORRECT.
. I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
, CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
II: ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
5
J E.D4 tR YA-AI
3 pERMIITEE NAME(PRINT)
c 1)--
Di T-123
0 SIGNATURE OF PERMII-CEE 3..-- ( DATE
2 .
ON
APPLICATION DATE ISSUE
DATE
CITY OF DIAMOND: BAR INSPECTION RECORD
1111111,!1""°hh, 11!!h
, '7.1 •
SET BACK i i F�OOR]OIST
FTC3S/FORMS/STEEL FHA REQMTS
E�ECTRIC GROUND ' ; . : UNDER F�OOR DUCT _
GROUND P�UMBING I ° . *UNDER FLOOR CONDUIT
SI.AB GRADE - i -- - . ,
T--E—M-P—-P-.0-W E-R I - ,i FIREPt_ACE FOUNDATION
-WATER-SERVICE --i - i !FIREPLACE BOND BEAM
! : MID HT. BOND BEAM
I—
ROOF SHEATHING i ' !8 FT. BOND BEAM
FINAL BOND BEAM
FRAMING/VENT I�P,TION 1
ROOFCOVER . PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ,...
I ROUGH GRADING
ROUGH P�UMBING FINISH GRADING
i
SHOWER/TUB TEST ,I 'POO E TR C
EXT. LATH/SIDING 1 i POOL FENCING
- I
WAL�INSULATION . ,POOL FINAL
�
CEI�ING INSU�ATION . ^OFF SITE IMPS.
• ---i
DRYWAL�NAI�ING ,
1DEDICATIONS
SEWER I *FINA�ENG. i
. _ , i
SEPTIG TANK ' LANDSCAPEIIRRIG. I
SEEP P—IT/L.�. I ; ON SITE IMPS.
'G A S—A—I R-TES-T—-- it.4. i FINA�Z-ONING
FINA�CONST V FIRE DEPT. FINAL I
FINA�HEATING 447 . i HEA�TH DEPT. FNAL
. 'DEV. FEES PAID
FINAL E�ECTRIC .0,
FINAL P�UMBING ; ENERGY
„ I
. 111 r.''.10.: ' . .
COMMENTS ,
TANK SIZE
PITJU SIZE
,,..., ,..
��
SEPTIC ..- ,-
SEEP ....."...seri.,.
.i4.... , . . ���� . .
-; . .-.. ..!.' -.i-.
. . ���
- -- 1...,. k
. , ,.... . „ ,,,•
_ .f.-:-:,_.--e.: ••2.-
... .. .4
. '�.-.
l, ' I
PRESS FIRM�Y
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTFY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-31ll
BUILDING PERMIT APPLICATION
JOBSITE •I n
ADDRESS 7 a'Wehc:ilvt;il trf
APN LOT 8 TRACT ifekg,
OWNER 04 B-/V kr o Ai
ADDRESS 30 T g L)".a pa...tti 0 r<.
crry deahvga Rovezip qt.?AS"TE�.
APPUCANT KO 0••-R. y44„ht TE�L. h., ,S2r3
CONTRACT°- . ' <._ -.... , Ili CI
ADDRESS 1 illEarail
crry VistkivAt ZIP e' TEL 61,1617
ARCHJENG/
DESIGNER 3' C. ahr.61.5
ADDRESS I 10-).)... arc*.vto, rsewy
CITY fre0 AI-ZIP 4,41*XELOI(I.).156.1.21
/ava.14...
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE I.AW FOR THE FOL�OWING REASON(SEC. 703/.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTEFL IMPROVE, DEMO�ISH. OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE.A�SO REQUIRES THE APP�ICANT FOR SUCH PEFIMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE�P,W(CHAPTER 9(COMMENCING WITH SECTION 7000 OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROIA AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 70316 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS($500).):
0 I,AS OWNER OF THE PROPERW,OR MY EMPLOYEES WITHWAGES AS THEIR SO�E COlAPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUS'.
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WM BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BULDING OR IMPROVEMENT IS SO�D WITHIN ONE YEAR OF COMPLE-
DON,THE OWNER-BUI�DER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE),
EII AS OWNER OF THE PROPERTY AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS cooE THE CONTRACTORS LI-
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PRO)ECTS%ATHA CONTRACI'OR(S)�ICENSED PURSUANT TO THE CONTRAG
TORS�ICENSE I.AW).
CI I AM EXEMPT UNDER SEC. BE P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, MID
WY�ICENSE SIN FU�L FORCE AND EFFECT.
LICENSE Ct_ASS 6,G1 6-s-4. �IG. NO. 661; sto
DATE D 1 CONTRACTOR At i Ir:.tiOtaft.r-:
WORKERS'COMPENSATION DECLARA,TION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DEC�P,RATIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE IABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
X. I HAVE AND WIL�MAINTAIN WORKERS COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IJaBOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATI INSUSANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER S4A+4.. KC'
POLICY NUMBER 0-1D—0 3
{THIS SEMEN NEED NOT BE COMFLETED OF THE PERMIT IS FOR COE HUMPED CO�LARS(SIOD)OR LESS).
1 CERTIFY THAT 94 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SOAR TO BECOME SUBJECT TO THE
INORKERE COMPENSATION LAWS OF CA�IFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: (1 c•b3 APP�ICANT: Ito tylig. yiptil
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFU�AND SHAL�BE
SUEUECT AN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOL�ARS($I00,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE,INTEREST.AND ATfORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3050,CM. C.).
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
lAGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
F-0 61 YkA)1
PERMIITEE NAME(PRINT)
ll,-(r-0 3
SIGNATURE OF PERMI'f"f DATE
APP�ICATION
DATE
PERMIT.DO(.0 P/C
NUMBER #C)3
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
0
PROPOSED
N0.
UNITS
USE
DWE�.
N0. N0.
STORIES BEDROOMS
0
ill
w DESCRIPTION S0. Ff. FACTOR PSF ADJ.AREANA�UATION
u-
0
Z
SFFI/ADD/REM
Garage/Carport
Patio/Deck
Pool/Spa
Re-Root
E
-J Commercial -
5
a)
, -.... -.--
-.tri7-...- 4c ,_Arttl'fgigr-t-
eq Cr40
valuation 499.4,9147,--• ADJ.AREA
QUANTITY DESCRIPTION FEE
(.-)
cC
I-
0 0
w
Il
L
Mow
I/C- ...
IIP
2
E.
2 ...L.,::....,E.w.-2.1
ci_
p—TRAf --A--t ...s 0
0
C.)
<
I ,v•0 4 —TS
c..)
tu
2
CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE:
{:) 3(c,8,7c)
5 1 .4-0
•=4-C:i -
1-k-(7.7)CS
':/-a•-.. . 0
i c)c)•c--;
--. •aZI)
ei7S.S.ttS3
• :3"/(S. 43
TOTAL FEES 31 E. •4t-C;)ct-i e-t€.. f,
COMMENTS
......�,
RECPT. NO PAID BY VALIDATION —
WHrrE-DepKrtmeoit Copy.YEL�OW-Finance Copy. PINK-Assessor Copy, s
s#, CITY OF DIAMOND BAR INSPECTION RECORD
00.04 •'• ,
,'.
1 : 'FHA REQMTS
ELECTRIC GROUND._ . .. ...., . UNDER F�OOR DUCT I
GROUND P�UMBING --7-4'91: ,/° 'UNDER F�OOR CONDUIT ii.... 7.77/ 1
SI.AB GRADE _ _ FIREP�ACE FOUNDATION
TEMP POWER .-FIREP�ACE BOND BEAM
' MID HT. BOND BEAM
WATER SERVICE -'8 FT. BOND BEAM
ROOFSHEATHING
FRAMINGNENTILAT/ON . , ,• FINAL BOND BEAM 1
ROOF : PRE-GRADING
COVER
ROUGH
. . ; BENCHING .
HEATING
ROUGH ELECTRIC I !ROUGH GRADING .
ROUGH P�UMBING ,'FINISH GRP,DING
- . _, ,:-71f9I Aleift
SHOWER/TUB TEST
EXT. LATH/SIDING
WAL�INSULATION ;I POO�FINAL I
CEI�ING INSUTAT:ON ! !OFF SITE IMPS,
DRYWAL�NAI�ING l: if
SEWER . "/. f I'..:',11../tsgi. !DEDICATIONS
SEPTIC TANK ! — . ; FINAL ENG.
SEEP PIT/L.�, .; .
GAS AIR TEST 44,114'W i�P,NDSCAPEJIRRIG.
' �IA . Oiil;
1-
1 ; ON SITE IMPS,
, i
I FINAL ZONNG
I;
I FIRE DEPT, FINAL
'HEALTH DEPT. FINAL
i DEV, FEES PAID
; ENERGY
I ,
COMMENTS
s SEEP SEPTIC TANK
PITlU SIZE
SIZE ..,
,
„i•
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-31ll
BUILDING PERMIT APPLICATION
PRESS FIRM�Y
APP�ICATI
DATE
s./ 12)ti., PERMIT Th,_...,po. �I P/C
I NUMBER"""" '"--""-1-# (... -Tc.. 1„..1,3G
ISSUE
DATE
TYPE OCC
CONST GROUP
FRONT SETBACKS
ZONING REAR RW 0
SIDE
0
SIDEJSIDE STREET RW 0
0
N0. PROPOSED
UNITS •
USE . i .
DWE�.
C>ss 1
N0. N0.
STORIES BEDROOMS
DESCRIPTION S0. Ff. FACTOR PSF ADJ.AREANA�UATION
(.0 SFFOREM
Garage/Carport
I�I
L�I
IL PatioJDeck
0
z
Pool/Spa
Re-Root
6
--I Commercial -
5
co
Valuation e....,c)c- CD AD7.AREA
QUANTITY DESCRIPTION FEE
-J
<
0
f=
)- 3 _i 5 f 1.4)strrif^ 4C-> • ..-S,->
0
U.i
-.I
LU
0 4^,c c,
z
rT3
m
-J
IL
..=1 3 i 4k-. I--Tea {SLilfr
<
0
2
<
X
0
L�I
2
CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE: Gi .•-'3
*".3' -S Scs
41"<:3
41-')• 'S'--
1 5,
6, s ct. -a.6
,
—..??8 4
TOTAL FEES"71 1 ,9 1 .7-1 (t;,---1 , --1 3
COMMENTS
RECPT. NO. /I 3'9.9 PAID BY Ve ef•-.0 VA�IDATION 0 V.Y1
WHITE—Department Copy,YE�LOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS DENSE�AW FOR THE
FOL�OWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE.ANY CITY oR COUNTY WHICH REQUIRESA PERMIT TO
CONSTRUCT.A�TER,IMPROVE. DEMOUSH. OR REpAIRP,NY STRUCTURE. PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE
APP�ICANT FOR SUCH PERMIT TO A�E A SIGNED STATEMENT THAT HE OR SHE IS�ICENSED PURSUANT TO THE PROVISIONS OF
THE CONTRACTORS�ICENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7030)OF DIVISION SOP THE BUSINESS AND
PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND 1HE BASIS FOR THE AL�EGED EXDAPTON.ANY
VIO�ATION oF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUB]ECTS THE APPLICANT TO A CIVIL PENALTY OF NOT
MORE THAN FIVE HUNDRED DO�LARS($Soo).):
DI,AS OWNER OFI'HE PROpERTy,OR My EMP�OYEES WITHJNAGES AS THEIR SOLE COMPENSATION,WIL�DO THE WORK,AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS
LICENSE�AW DOES NOT APPLY To AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO DOES SUCH
WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMP�OYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT
INTENDED OR OFFERED FOR S A�E IF. HOWEVER,THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF
COMP�ETION.THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR IMPROVE
FORME PURPOSE OF SALE).
0 I.AS OWNER OF THE PROPERTY AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE
PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS UCENSE lAW DOES NOT APP�Y TO AN OWNER OF
A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)
LICENSED PURSUANT TO THE CONTRACTORS UCENSE�AW)
0 I AM EXEMPT UNDER SEC B 8,P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH
SECTION 701:0)OF DNISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY UCENSE IS IN FUL�FORCE AND EFFECT.
LICENSE CLASS 6 C—)/ LID. NO. 66Y9 7 4C4
DATE 0) CONTRACTOR 44 6-tital..7,--%
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARA,TIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'COMPENSATION,AS PROVIDED BY
SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
f."-^ I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTOR 3700 OF THE I.ABOR
CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICI4 THIS PERMIT IS ISSUED MY WORKERS'COWENAToN INSURANCE
CARRIER AND POLICY NUMBER ARE
CARRIER 4�. fe4,4
PO�ICY NUMBER - . 3
(THISSECTICN NEED NOT BE COMF�ETEDOF THE PERMIT IS FOR ONE HUNDRED=LARS(SIOD)OR LESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHA�L NOT EMP�OY ANY PERSON
IN ANY MANNER SOAR TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I
SHOU�D BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE. I SHALL
FORTHWITH COMP�Y WITH THOSE PROVISIONS.
DATE: 1—.4—0) APPLICANT fa),(1-1/k.yirpv,
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU�.AND SHAL�BE SUB7ECT AN EMP�OYER
TO CRIMINAL PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND DOL(ARS(St 00,000),IN ADDMON TO THE COST
OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT THERE IS A CONSTRUCTION�ENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPUCATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.I AGREE TO
COMP�Y WITH A��CITY AND COUNTY ORDINANCES AND STATE IJaWS RE�ATING TO BUILDING CONSTRUCTION.AND HEREBY
AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION
PURPOSES
PERMRTEE NAME(PRINT)
Ito6cletk YAM
SIGNATURE OF PERMITi'EE DATE
JOBSITE or,
ADDRESS ,,.0 14/vb.ltl OR
APN OWNER ADDRESS CITY APP�ICANT
LgT_a_TRACT
CFIE/tf I-l�,'/
Wivtilk.Y`t
ZIP 4/1J4,:y:-TE�.
TELk.f,
CONTRACTOR ADDRESS
CITY WO ZIP i TEL ARCHJENG/
DESIGNER
ADDRESS
CITY ZIP
TEL
407
CITY OF DIAMOND BAR INSPECTION RECORD
:•244_l/ ' , 1 ; -4'- ; 1 UNDER F�OOR CONDUIT .
.GROUND PLUMBIfsG . 3 I
S�AB GRADE : : FIREPLACE FOUNDATION
TEMP POWER FIREPlACE BOND BEAM
E:VATER SERVICE - ; I--
I : MID HT. BOND BEAM
ROOF SHEATHING 8 FT, BOND BEAM
FTR-AMINGNENTI�ATION -A-17-a 44 . ; FINAL BOND BEAM
ROOFCOVER
,PRE-GRADING
UGH HEA\-G BENCHING
F*1:&4*.8440 i 4 0 0 p4G fithlefts
ROUGH ELECTRIC .3-4-d ., y-SW—A..
ISHOWER/TUB-EST 3-4-0
I
CEI�ING INSU�ATION
; FINISH GRADING
; ; POOL ELECTRIC
i POOL FENCING IliZafp
I P00�FINA - -or . Y i
!OFF SITE IMPS.
DRYWAL�NAI�ING
SEWER DEDICATIONS
SEPTIC TANK ; I FINA�ENG,
SEEP PITIL�. , LANDSCAPEARRIG.
: GAS AIR TEST-
•ION SITE IMPS.
. FINAL ZONING
FINA�CONST 1 4 ; I FIRE DEPT, FINAL
FINA�HEATING taillr' •,
; , HEALTH DEPT. RNA
FINAL E�ECTR;C ; DEV, FEES PAID
FINAL P�UMBING ENERGY
COMMENTS
SEPTIC TANK SIZE SEEP P T/U SIZE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE 'N a,
bIA',A 4 jvi hi DR,
ADDRESS.7 Or
APN LOT @- TRACT 4g rrer9
OWNER aro/ At PA.I
ADDRESS ;Oi g-uh".1-IA 4 W Vik
CITY tik 044,1 15;1 ZIP CA TEL
APP�ICANT tzp -avr..... y4747 Tell Dv 6761_krsig-
CONTRACTOR i+-4..Ci),..44.5bi......-• ,....---.4 •
ADDRESS 3Ib ri.54.a lei•44,
CITY tid 4. 11,-.4-- ZIP 400 TEL(2Vi_gt-421%,
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PER7URY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOL�OWING REASON(8E6.7031.5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
OOUNTYWHOH REOUIRESA PERMIT TO CONSTRUCT,A�TER.IMPROVE, DEMOUSH,OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS�F
CENSE t.AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FORME AU_EGED EXEMP-
TION.ANY VIOLATOR OF SECTION 7031.6 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOLtARS(5500)5
01.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITHWAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMP�OYEES,PROVOED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVEFL THE BUILDING OR IMPROVEMENT IS SO�D WITHIN ONE YEAR OF COUPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 1.0$OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH LICENSED CONTRP,CTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U-
CENSE�P,W DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS�ICENSE�AW).
IT INA EXEMPT UNDER SEC 9.5 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY UCENSE IS IN FU��FORCE AND EFFECT
LICENSE CLASS LC N0.
DATE CONTRACTOR
WORKERS COMPENSATION UECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY ONE OF THE FO�LOWING DECLARA,TIONS.
I HAVE AND WIL�MAJNTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE.AS REQUIRED BY SECTION
3700 OF THE lABOR CODE. FOR THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS COIIPENSATON INSURANCE CARRIER AND PO�ICY NUMBER ARE.
CARRIER 5 .614. fi,AA
POLICY NUMBER IoqO ."'12 3
(THISSECTON NEED NOT BE COMFLETEDOFTHE FE IT 0 FOR ONE HUN)RED DO�LARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE(ABOR
THOSESOVISIONS.
CODE,I SHALL FORTHWITH COMPLY WITH r)
DATE: OA t-0 3 APPLICANT: Yitiu,
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLIARS(0100,000).IN ADDMON TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE I.ABOR CODE,INTEREST.AND Al-fORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.),
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPUCATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH AL�CRY AND COUNTY ORDINANCES AND STATE�AWS RElATING TO BUI�DING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
PA)J m y/d.Ai
PERAIIl�'EE NAME(PRINT)
, (1J-,-,S'D 3
SIGNATURE OF PERMII�'EE DATE
PRESS FIRM�Y
APP�ICATION
DATE
PERMIT...-, P/C ,._,
NUMBER,--r-C)444Q,#IC.„V',S
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW CI
0
SIDE/SIDE STREET RW 0
D
PROPOSED
N0.
UNITS
USE
DWE�. pa fi„ covy-----
N0. N0.
STORIES BEDROOMS
U)
Iil
U.1 DESCRIPTION SQ. Ff. FACTOR PSF ADJ.AREANA�UATION
U-
(...1
z
SFR/ADD/REM
GarageJCarport
Patio/Deck 6Lro
Pool/Spa
Re-Roof
3
r Commercial
5
co
Valuation 044 0 AD).AREA
QUANTITY DESCRIPTION FEE
<
0
2
I-
Lu
-.l
w
a
z
2
M
n
-J
0-
—I
<
0
2
a
x
C-)
co
2
CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE: - 1 (e...), I SD
(.404t. (AC:i r--A
I
TOTAL FEES /0/-
COMMENTS
RECPT. NO.Am EI ta_PAID BY VAUDATION
WHITE—Depanment Copy,YEL�OW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
4pVr
CITY OF DIAMOND BAIR INSPECTION RECORD
SET BACK , , I. a_ i F�OOR JOIS I
FIGS/FORMS/STEEL - : FHA REQMTS
E�ECTRIC GROUND , ' T _ i UNDER FLOOR DUCT i-
GROUND P�UMBING ; + UNDER F�OOR coNourr
S�P,B GRADE - ,FIREPLACE FOUNDATION
TEMP POWE--R- I i FIREP�P,CE BOND BEAM
WATER SERVICE I MID HT. BOND BEAM
ROOF SHEATHING . . -0( .
i-P:11\,'-.' ' ' r . .',:.' 'i ' I /4,/t.
! 8 FT BOND BEAM
ROOFCOVER
i FINAL BOND BEAM
I PRE-GRADING
ROUGH HEATING .
iBENCHING
ROUGH ELECTRIC I I ROUGH GRADING
ROUGH P�UMBING t
i FINISH GRADING
SHOWER/TUB TEST , I E�ECTRIC .
EXT. LATH/SIDING ., I P00�FENCING t _
WAL�INSULATION - 1
. i POOL FINAL ,--
, : i
CEI�ING INSU�ATION i OFF SITE IMPS,
DRYWAL�NAI�ING ; . I DEDICATIONS I -
SEWER - . ; , !
SEPTIC TAN-K- ' -- -- i FINA�ENG.
. _ _ __ I�A-ND-SCA-DE/RR-1G
SEEP PIT/L.�. ON SITE IMPS.
GAS AIR TEST _ 1 FINAL ZONING
FINAL CONST. I FIRE DEPT FINAL
FINA�HEATING . 'HEALTH DEPT. FINAL .
FINAL E�ECTRIC ' 1 DEV. FEES PAID
FINAL P�UMBING i ENERGY
„ . . . .
COMMENTS "
SEPTIC TANK SIZE
SEEP PIT/U SIZE
,,,, ----- -
-7