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CITY OF DIAMOND BAR �JF
11 II&N [11ii I I ' DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
JOB SITE ADDRESS �?
APN � � � LOT KK� t�' TRACT 0
OWNER A4 C-7
ADDRESS irk t Js?^ aCM _
CITY rift -10' r - ZIP TEL.
APPLICANT !2,2'i &. 73 �
CONTRACTOR
ADDRESS
CITY ZIP Ti
ARCH/ENG/
DESIGNERSs°
ADDRESS
CITY , f'e4r&i',ag� Z!P EZ�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 items) [Section 7031.5, Business and
Professions Cade: 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 statementthat he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 r4 Division 3 of the Business and Professions Code] orthat he or she is exemptfrom licensure and the basis for
the alipged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of :^,c more than live hundred dollars ($500).
] I, as owner of the property, or my employees with wages as thefr sole compensation, will do
_)all of or (_}portions
Jf the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who, through smployees' or personal effort, builds
or improves the property, provided that the Improvements are not intended or offered for sale. If 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.).
11, as owner of the property, am exclusively contracting wlth 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
builds or improves thereon, and who contractsforthe projects with a licensed Contractor pursuanitothe Contractors' State
License Law.).
U I am exempt from licensure underlie Contractor's Stale License law for the following reason(s):
Date: Sign:
I By my sign: tum te!ev! 1 acknowledge that, exceptfor my personal residence In which I must have resided for at least one
i year priorto completion of the Improvements mvered'uy this permit,I cannot legally ser: z stmu<ure that I have Irel1t?s am
)wrier -builder if ft has not been constructed in its entirety by licensed contractors. ' understand that a copy o1 the
clicable IRW. Section. 7044 of i1-,, easiness and Professions Code is aysaable upon request when this application is
'Miffed or at the following Web site: http/wwwleginfo.ca.gcv/cBlaw.htmf
LICENSED CONTRACTOR'S DECLARATION
,reby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
Oivision 3 of the Business and
Professions Code, and my license is In full force and effect
_CENSE CLASS: 1 LIC. NO.: � � j a�
EXP. DATE: `" •-- f ..� � CONTRACTOR: , r,_4 • _14 -s t `V Z
WORKER'S COMPENSATION DECLARATION
'- I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
have and will maintain a Certificate of Consent to Self -Insure for Workers Compensation, as provided by
Secllon 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 perfomiante of the work for which this permit is issued. MY Worker's Compensation Insurance Carrier and
Policy Number are: & �
s
CARRIER P
3 POLICY NUMBER
5
(f HIS SECTION NEED NOT RE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I cortifythat inthe performance of ne workforwhich this perml is issued,1 shall not employany peman in any mannerso astm
o become subject to the Worker's Compensation Laws of California. And agree that if I should became subject to the Worker's
JJ Compensation provisions of Secton 3700 ofthe Later Code,1 shall forthwith comply with these provisions.
J DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
7 penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cast of the compensation,
j damages as provided for in section 3708 of the labor code, interest and attorney's fees.
CONSTRUCTION LENDING AGENCY
J I hereby affirm under penalty of perjury 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:
J'
1 certify that I. have read this application and state that the above iVhBb
rre I agree to comply with all city and
county ordinances and state laws relating to building constructionthl. orize representatives of this county to
enter upon the above-mentioned property for lnspectlon pu an�PERMITTFF AME(PRINT)`E SIGNATURE R ITTEE _4r 4y IDATE
V
APPLICATION DATE: 1 � 1 -1 f i P/Cq# '�.
ISSUE DATE: �%� +PERMIT# : R "` ''^�"""
TYPE CONST. OCC GROUP:
Scope of Work d,ut-""!�">u k �'3."s✓`
# OWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. ARF.ANALUATION
SFR/ADD/REM
Garage/Carport
UJ
Patio/Deck
tmi
Pool/Spa
zRe
-Roof
Commercial
m
Valtuanan:. o • + Adj. Area:
QUANTITY DESCRIPTION FEE
a
U
E
w
w
c�
a
m
U_
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY PIC:
LNERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE: %
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTALFEES �- DL
COMMENTS:
P/CZ 3PAID BY: \ VALIDATION:
RECEIPT # �"�`�f PA1�BY;Ii 72 VALIDATION:
WHITE: — Department Copy, YELLOW — Finance Copy, PINK—Assessor Copy
N
COMMENTS: