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= J_ CITY OF DIAMOND BAR
} 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,
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JOB SITE ADDRESS . t
APN LOT TRACT
OWNER
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CITY ZIP "TEL."
APPLICANT "
CONTRACTOR
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CITY P TEL.
ARCH/ENG/
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CITY ---"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 itam(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 pursuantto 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 bas€s for
the alleged exemption. Any violation of Section 7031.5 by any applicanttor a permitsubjecLs the applicantto a civil penalty
of not more than five hundred dollars (5500).
(_)1, as owner of the property, army employees with wages as their sole compensation, wilt do U all of or U portions
of 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 employees' 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 OwnerBuilderwi€I have the burden of proving that it was not built
or Improved for the purpose of sale.).
O 1, 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
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuatto the Contractors' State
License Law.).
U I am exempt from licensure under the Contractor's State License law forthe following reason(s):
Date: Sign-
By my signature below I acknowledge that, exceptfor my personal postdates in which I must have resided for at least one
year prior to completion of the improvements covered by this pets l cannot legally sell a structure that 1 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 Web site: httplwww.loginfu.ua.gov/calaw,html.
LICENSED CONTRACTOR'S DECLARATION
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 Business and Professions Code, and my license is in full face and effect.
LICENSE CLASS: LIC. NO.:
Exp. DATE: ONTRACTOR:
WORKER'S CO PENSATIOH DECLARATION
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 Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the work forwhich this permit is issued.
I have and wiil maintain Worker's Compensation insurance, as required by Section 3700 entire Labor Code, fur
the performance of the workfor which this permit is Issued. My Worker's Compensation Insurance Carder and
Policy Number are: U'
CARRIER 4A F SA
POLICY NUMBER a
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I eerfifythat in the performance ❑fthe warkfor which this perp-dis issued, I shall not employ any person in any mannerso a; to
become subject to the Worker's Compensation Laws of California, And agree that if I should become subject to thio Worker's
Compensation provisions of Section 3700 ofthe Labor Code, I shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
damages as provided for in section 370E of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
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:
I certify that I have read this application and state thatthe above information is correct. l agree to comply with all city and
county ordinances and state laws relating to building conslruclion, and herebysulhorize representatives of this county to
rty for Inspection gp poa
enter upon theMT�7
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PERMITTEE
SIGNATURE DATE
APPLICATION DATE: Ii l�
ISSUE DATE: PERMIT# :
TYPE CONST.
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OCC GROUP:
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Scope of Work
# DWEL. UNITS # STORIES
# BEDROOMS
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DESCRIPTION SQ. FT, FACTOR PSF
ADJ. AREAIVALUATION
SFR/ADD/REM
Garage/Carport
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Valuation;
Adj. Area:
QUANTITY DESCRIPTION
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
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MECHANICAL:
INSPECTION FEE:
ISSUANCE:
(p,
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
2�
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTALFEES
COMMENTS:
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P/C: PAID BY:
RECEIPT# tl ✓[ PAID BY:
VALIDATION:
VALIDATION:��
WHITE— Department Copy, YELLOW — Finance Copy, PINK— Assessor Copy
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