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CITY OF DIAMOND BAR
i r
DEPARTMENT OF COMMIJNITY & DEIT)ELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 8bI-3I17 Building Inspection Hotline (909) 839-7027 PRESS
°$9 BUILDING PERMIT APPLICATION www.cityofdiamondbar.com build ing@diamondh FIRMLY
JOB SITE ADDRESS Sa� ��ZC()'Y%
APN LOT TRACT
OWNER y eGz
ADDRESS
CITY 71PT -L.
APPLICANT Jly{� TEL.
CONTRACTOR `[ ee_L.*,T2-_ f C
ADDRESS 711&' / rryy a f'=s2 f �C Y`
CITY C-0f✓iyl rte. ZIP _TEL
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 reasons)
Indicated below by the chockmars(s) I have placed next to the applicable ffem(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 be 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 exempt from licensure and the basis for
the alleged exemption. Any violation of Sectlon 7039.5 by any applicant for a permitsubjectsthe applicant to a civil penalty
Of not more than five hundred dollars ($500).
U I, as owner of the property, or my employees with wages as theirsole compensation, wT11 do {_) all of or [ j portions
of the work, and the structure is not intended or offered for sale (Sectlon 7044, Buslness 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 property, provided thatthe improvements are not intended or offered for sale. If however, the bull 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 safe,).
(i 1, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sectlon
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 contracts for the projects with a licensed Contractor pursuantto the Contractors' State
License Law.).
U i am exempt from licensure underthe Contractor's State License law for the following reason(s)r
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 permiO cannot legally sell a structure that I have built as an
owner-hullder 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 Web site: httplwww.leginfo.ca.govlcalaw.html.
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 ofthee Business and Professions Code, and my license is in full force and effect.
EXPENSE C CONTRACTT��
EXP. DATE: " � ` r
WORKER'S COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to SelfInsure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, forthe 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 of the work for which thls permit Is issued, My Worker's Compensation Insurance Carrier and
Policy Numb are:
POLICY NUMBER LQ - I
(THIS SECTION NEED NOT BE COMPLETED IFTHE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OA LESS).
I certlythatin the performance of the work for which this permit is Issued, I shall not employ any person in any manner so a;to
become subject to the Worker's Compensaton Laws of California. And agree that if I should become subject to the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with 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 ($10o,D00), in addltien to the cost of the compensation,
damages as provided for in section 3708 of the labor code, Interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
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, Cly. C.),
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that l have read this application and slate that the above Informatfan 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 the above-mentioned property for inspection purposes.
rLa?a "4 -
(PRINT)
DATE
WHITE — Department Copy, YELLOW — FTnance Copy, PINK — Assessor Copy
ca.gov
APPLICATION DATE:
17 J .�
ISSUE DATE: dr
P/C#
PERMIT# : r Ir- �7 -1 (-7
TYPE CONST.
OCC GROUP:
Scope of Work �l s�� r
C I I EC r/Lar�
# DWEL. UNITS
# STORIES # BEDROOMS
SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
EMportw
WDLSCRIPTION
W
cL Pool/Spa
ZRe -Roof
i Commercial
03
Valuafon:
Adj, Area:
QUANTITY
DESCRIPTION FEE
m
tid i
d
_U
a-
T
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:'
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
V
COMMENTS:
PAID
DY: VALIDATION:
RECEIPT If °
PAID BY:.ir � ./.� `�' VALIDATION:
WHITE — Department Copy, YELLOW — FTnance Copy, PINK — Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS: