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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
L
21810 Copley Drive, Diamond Bar, CA 9]765 PRESS
w (909) 839-7020 Fax. (909) 861-3117 Building Inspection "otline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
APPLICATION DATE: N= P/C#
JOB SITE ADDRESS C "'_
[ISSUE DATE: d+1 2XI 6PERMIT# :
APN
OWNER
ADDRESS
CITY
APPLICANT
CONTRACTOR
CITY
TEL.
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 reasons)
indicated below by the checkmark(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 applicant for the permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division 3 of the Business and Professions Code] or that he or she Is exemptfrom licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicantfor a permit subjects the applicantto a civil penalty
Of not more than five hundred dollars ($500}.
(_U I, as owner of the property, or my employees with wages as their sole compensation, will do U all of or (J portions
of the work, and the structure is not intended or offered for sale {Section 7044, Rusimeae and Professions Cade: The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or improves the property, provided that the improvements are not intended or offered for sale. It however, the building or
improvement is sold within one year of completion, the Owner -Builder will have the burden of proving that It was not built
or Improved for the purpose of sale.).
(-) I, as owner of the properly, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Coda, The Conhaclors' State License Law does not apply to an owner of property who
builds or improves thereon, and who contractsfmthe projectswith a licensed Contractorpursuantto the Contractors' State
License law.),
U I am exempt from licensure under the Contractor's State License law forthe following reasons)
By my signature below I acknowledge that, exceptfor my personal residence in which I must have resided for at least one
year prior to completion of the Improvements covered by this permit,I cannot legally sell a structure that I have built as an
owner builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or at the following Webster httplwww.leginfo.ca-gov/calaw.html.
LICENSED CONTRACTOR'S DECLAHATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Rusiness and Protesslons Code, and my license is In full force sndj ffect
LICENSE CLASS: LIC. NO.:'?'`
EXP. DATE: CONTRACTOR:
CONTRACTOR„
WORKER'S C0MPEN$AT1Ddb�5ECLARAiI¢H
k HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING 1)(9 ARAT10NS:
I have and will maintain a Certificate of Consent to Self Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance blithe workfor which this permit Is issued. My Worker's Gompensation Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
{TRIS SECTION NEED NOT BE QCMRFf J r7HEPERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS}.
I certiWirzil1t�a performance of lhe.-work , for which chis perri t is issued, IIIn4olploy any person In any manner sow to
become suhj6Et to the y4orker's Corhpensation i. s cf CallfQymIa. And arjree the( if I should become subject to the worker's
f:nmeasnn nrnvm—, of Rrr:tinn 1700 rfifhe, Lader Cade.4 sK.fodVM lith-CAm'PlYwlth those provislprls. ,,
Wfflli B: Faure tp secure Wor ans'CompBhsation c erage,ie' unlawful, and shall subject an employer to criminal
penalties and dviVilnes up to one hundre0housand ollars 41CiV600), In addition to the cost of the compensatlon,
damages as provided for In section 37084the labor wide, interest; and attorney's fees.
CONSTRUCTION LRDruING AGENCY
I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance ofthe work for
which this permit is issued (See. 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 comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county, to
enter upon te-,apgve-mentioned property for insgectlon purposes.
DATE
TYPE CONST
Scope of Work Z
OCC GROUP:
If
# DWEL. UNITS S # STORIES 9 - # BEDROOMS
N
DLSCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADDlREM
Garage/Carport
Patiol eck
Pool/Spa
Re -Roof
Commercial
Valuation: Adj. Area:
CONSTRUCTION:
QUANTITY
DESCRIPTION FEE
SMIP:
PLUMBING:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
°
PLOT PLAN:
ZONING CLEARANCE:
2
m
a
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U
CONSTRUCTION:
��
PLAN REVIEW:
ELECTRIC:
SMIP:
PLUMBING:
ENERGY PIC:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
°
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPT # PAID BY: VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, P1 NK— Assessor Copy
ClITY OF DIAMOND BAR
INSPECTION RECORD
LUMMENTS: