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DIAMOND $AI:
JOB SITE ADDRESS
CITY OF DIAMOND BARt._. t�
DEPARTMENT OF COMMUNITY & r ¢�'VELQPMENT SERVICES PRESS
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861.3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION tivinv.cityofdiamondbar.com building@diamondbarca.gov
Yl' 3 I 1 APPLICATION
APN LOT TRACT
OWNER
ADD S
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+ ZIP '145`13 TEL
CITY.
APPLICANTi!'II('.4lrne�i�yAttTEL.
CONTRACTOR k>lnkXA_��
ADDRESS 6� - "�
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DESIGNER
ADDRESS
CITY
ZIP
OWNER -BUILDER DECLARATION
I hereby a€iirm under penalty of perjury that I am exempt from the Contractor's State License law for the reason($)
Indicated below by the chackmark(s). I have placed next to the applicable Iterl iScolien 7031,5, Business and
Professions Cede, Any clay or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to Its Issuance, also requires the applicant for the psrmltto file a signed statement that he or she
Is licensed pursuairl ns of the Contractor's
te
e Low
ng
ith Secon
7000 of Division 3 of theBusinessD end Professions Cade[ orththat or (Chapter
r she sxempt from Cll a sureiadWhe basis for
the alleged exemption. Any vlolallon of Section 7031.5 by anyappricantfor a permlt subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).
UI,aoftheproperty,ormyamployeeswithwagesasthefrsolecompensation,wltido{}allofarI-) portions
sawner
of the work, and the structure Is not Intended or offered for $ala (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or Improves the properly, provided that the Improvements are not Intended or otfefed far sale. If however, the building or
Improvement Is sold wIthln one year of completion, the Owner-Builderwill have the burden of proving that It was not bulfl
or improved for the purpose of sale.).
O1, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors' State license Law does not apply to an owner of property who
buildserlmproves thereon, and whocontraolstorthe projectswith a licensed Conlrantor pursuant to the Conlraclofs' State
License Law.).
U I am exempt from licensure under the Contractor's State License law for the following reason(s):
By my signature below! I acknowledge that, except for my personal residence In which I must have fesided for at least one
year red by
structure that I
prior to
if It completion of
not been constructed Inhe Improvements eIts a 1lrettypbynliio
licensed alu dustand that avbuilt
copy ofs an
the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this appllcation Is
submitted or at the following Web site: hitplwvnw.legfafo.ca.gov/calavr.html.
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l herehy affirm under penaityet perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of DIvlslon 3 of the Business and Professions Codaand my license Is in full force and effect.
LICENSE "SS:C CIO Q LIC. NO.: m"' M
EXP. DATE: ? ' 2 -%I1 -L? CONTRACTOR:
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PFNALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Wofker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issuod.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance of the wofkfarwhlch this permit Is issued. My Worker's Compensation Insurance Carrier and
PolicyNum "re: �_I I ill c.
CARRiFR `-'� Fl II
POLICY NUMBER . �C -------
0
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t certify thatI n the performance otthe vmdcforwhich this permit Is Issued, I shall not employ any person In any manner so asto
become subject to the Worker's Compensation Laws of California. And agree that If I should become subject to the Worker's
Compensation provisions of Sscton 3700 of the Labor Godq shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage Is unlawful, and shall subject an employer 10 criminal
tion
damages as provided for In section 3708 oft he laborthousans del Interesars t and attomey'si fees-
CONSTRUCTION
ees She cast of the compensation,
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there Is a Constful Lending Agency for the performance of the work for
which this permit is Issued (Sec. 3097, Civ. C.),
LENDER'S
LENDER'S ADDRESS:
I certify that I have read this application and state thatthe above information Is correct. I agree to comply with all city and
county ordinances and state laws Waling to building construction, and hereby authorize representatives of this county to
enter upon the U0 e-11leploonnedd p party for I spection purer
PERMtTTEEN P INT) /7� ` 0 ?
SIGNATURE OF PERMITTEE DATE
ISSUE DATE:_
TYPE CONST
P/C#
OCC GROUP:
P�
Scope of Work�—
.� a I�
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AKLfVVALUAI IVIN
SFR/ADD/REM
GaragelCarport
PatiolDeck
Po-i/Spa
Re -Roof
Commercial
Valuation: Adj. Area:
wHITF — Department COPY, YELLOW — Finance Copy, PINK—Assessor Copy
QUANTITY
DESCRIPTION r ��
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a
a
a
x
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
Z
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
FEE:
( , _3i i
PRE -ALT
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
34-_3: O l6
PAID BY: L1 y VALIDATION:
RECEIPT # - - PAID EIY: L434 2-4 VALIDATION: Le—
wHITF — Department COPY, YELLOW — Finance Copy, PINK—Assessor Copy