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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861-3117 Building Inspection hotline (909) 839-7027
BUILDING PERMIT APPLICATION www.cityofdiamondbar.cora building@diamondbarca.gov
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APNLO 1 TRACT
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APPLICA sC 11LTEL- 714
74
CONTRACTOR
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasco(s)
indicated below by the chackmark(s), I have placed next to the applicable item(s) [Section 7031.5, Business and
Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to its Issuance, also requires the applicantfer the permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapterll) Commencing with Section
70DO of Division 3 of the Business and Professions Codel orthat he or she is exemptfrom licensure and the Basis for
the alleged exemption. Any violation of Section 7031.5 by any appllcantfor a permit subjects the applicant to a civil penaRy
o1 not more than five hundred dollars ($500).
C-) I, as ownerof the property, armyemployeeswilh wages as their sole compensation, will do (_)all of or() portions
of the work, and the structure Is not Intended or offered for sale (Section 7044, Business and Professions Cade: The
Contractors' State License Law does not applyto an owner of property who, through employees' or personal effort, builds
or improves the property, provided that the improvements are not intended or offered fur sale. If however, the trullding or
improvement Is sold within one yearol completion, the Owner -Builder will have the burden of proving that It was not built
or improved for the purpose of sale.).
wings owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors' State License Law does not apply 14) an owner of property who
buildsor Improves t emon, and Wnocontractsforthe projects witha licensed Contractor pursuant toBheContracters' SIa1e
License Law.).
U I am exempt from licensure under the Contractor's State License law forthe following reason($):
Date: Sign:
By my signature below 1 acknowledge that, except formypersonal residence In which I must have resided for at least one
year prior to completion of the Improvements covered by this parmit,l cannot legally sell a structure that I have built as an
owner -builder if it has out been constructed In Its entirely by licensed contractors. I understand that a copy of the
applicable law, Section 7064 of the Business and Professions Code Is available upon request when this application Is
submitted or at the following Web site: hitplwww.leginfo.ca.gov/cataw.hbnl.
LICENSED CONTRACTOR'S DECLARATION
I herehya#Irm under penalty of perjury that I am licensed under provisions of Chapter 0(commencing with Section 71
of Division 3 o1 the Bu..siness and Professions Code, and my license is In full force and effect"
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LICENSE CLASS: _ LIC. NO.:
FXP. DATE: - v"r CONTRACTOR:.'.. P F,-
' L;.1, _ x
WORKER'S OAIPEN� O 1 OH
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS'
I have and will maintain a Certificate of Consent to Self -Insure for Worker's € orappensation, as provided by
Section 3700 of the Labor Code, for the performance of the wank for which this permit Is issued,
have and will maintain Worker's Compensation loan rance, as required by Secgnn 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
4- Policy Number are:
CARRIER
POLICY NUMBER r
(IHISSECTION N NO BE COMPLETED IF THE PERMRISFOR ONE HUNDRED DOLLARS$1000RL€SS).
I certify that in the performance of the work for which this permit is issued, I shelf not employ any person in any manner so as to
became subject to the Worker's Compensation Laws of California. And agree that it I should became subject to the Workers
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith oomplywith those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shalt subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,€00), in addition to the cast of the compensation,
damages as provided for In section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penally of perjury that there Is a Construction Lending Agency for the performance of the work for
which this permit fs issued (Sec" 3687, Cly. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above Information is correct l agree to comply with oil city and
countyord' antes and state laws relating to building construction, and hereby authorize representatives of this county to
enterup the above mentioned property for inspection purposes.
PMMITIEE NIN INT),
SIGNATOR P MITIEE DATE
PRESS
FIRMLY
APPLICATION DATE: P/C#
ISSUE DATE: PERMIT# :
TYPE CONST. OPb� OCC GROUP:
Scope of Work
# DWEL, UNITS fl STORIES
s
# BEDROOMS
DESCRIPTION SQ, FT. FACTOR PSF
ADJ.AREA/VALUATION
SFWADD/REM
Garage/Carport
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Patio/Deck
W
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P001/Spa
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-Roof
Commercial
on
Valuation; 61Y
Adj. Area:
QUANTITY DESCRIPTION
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CONSTRUCTION:
PLAN REVIEW:_\.
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ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PHE-ALT FEE:
_ f3
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
�q .
P/C: PAID
`� BY:
RECE1PT0 �S'9—"T PAID BY: acid
VALIDATION:
QLVALIDATION:1;�Irl "
WHITE —Department Copy, YFL _0W— Finance Copy, PINK—Assessor Copy
CITY OF DIAD40ND EAR
INSPECTION RECORD
COMMENTS: