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CITY
ADDRESS
CITY
CITY OF DIAMOND BAR
DEPARTMENT OF COMN'UNITY .& DEVELOPMENT SERVICES PRESS
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027FIRMLY
BUILDING PERMIT APPLICATION wvww.cityofdiamondbar.com building@diamondbarea.gov
ZIP
ef i j, f j APPLICATION DAT%E: PIC#@
1 3 ISSUE DATE: i / � PERMIT# : � 1 � I
TRACT
ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that i um 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 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 fife 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 exempttrom Ilcensure and the basisfor
the alleged exemption. Any violation otSectlon 7031.5 by any applieantfor a permit subjectsthe applicontto a civil penalty
of not more than five hundred dollars ($500).
Ll I, as owner of the property, or my employees with wages as their sale compensation, will be (_) all of or O 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 completton, the Owner -Budder will have to burden of proving that it was not built
ion
r vedfor the purpose ofsale.).
owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
bor Imp rov as th a reon, and who contracts for the prolacts with a licensed Contractor pu rsu ant to the Contractors' State
License Law.).
U I am exempt from licensure underthe Contractor's State License law forthe following reason(s):
By my signature below I acknowledge that, except for my personal residence In which I must have resided for at least one
year prior to completion of the improvements covered by this permit) cannot legally sell a structure that I have buttes an
owner -builder if it has rot been constructed in its entirely 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 Wet site: http/www.leginfo.ca.gcvfcal8w,htrnl-
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 ttiusiness and Professions 4anlcWe is In me and effect.LICENSE CLAS � LIC. NO.:EXP. DATE.%- �'' 9' CONTRACWORKECN 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 Wife Labor Code, for the performance of thework 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 this permit Is issued. My Worker's Compensation Insurance Carrier and
Policy Numger are: r
CARRIER
POLICY NUMBER
(alts SECTION NEED NOT BE CCMPtEMD IF THE PERMITIS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that inthe performance ofthe work for which this permit is issued, I shall not employ any person In any manner so Esta
become subject to the Worker's Compensation Laws of California. And agree that If I should become subject to the Worker's
Compensation provisions of Section 370D of the Labor Cade, l 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 ofthe compensation,
damages as provided for in section 3708 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 certitythat l 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 construction, and hereby authorize representatives of this county to
enter upon the above-mentioned property for inspection purposes.
7 :� 4, t L-,,, --/o t
PFFMITTEE NAME (PRINT
DATE
TYPE CONST
Scope of Work
# DWEL. UNITS # STORIES
OCC GROUP:
# BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFFII REM
Garage/Carport
Patio/Deck
Pool/Spa
Re -Roof
Commercial
Valuatean: Adj, Area:
QUANTITY DESCRIPTION
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CITY
ADDRESS
CITY
CITY OF DIAMOND BAR
DEPARTMENT OF COMN'UNITY .& DEVELOPMENT SERVICES PRESS
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027FIRMLY
BUILDING PERMIT APPLICATION wvww.cityofdiamondbar.com building@diamondbarea.gov
ZIP
ef i j, f j APPLICATION DAT%E: PIC#@
1 3 ISSUE DATE: i / � PERMIT# : � 1 � I
TRACT
ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that i um 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 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 fife 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 exempttrom Ilcensure and the basisfor
the alleged exemption. Any violation otSectlon 7031.5 by any applieantfor a permit subjectsthe applicontto a civil penalty
of not more than five hundred dollars ($500).
Ll I, as owner of the property, or my employees with wages as their sale compensation, will be (_) all of or O 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 completton, the Owner -Budder will have to burden of proving that it was not built
ion
r vedfor the purpose ofsale.).
owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
bor Imp rov as th a reon, and who contracts for the prolacts with a licensed Contractor pu rsu ant to the Contractors' State
License Law.).
U I am exempt from licensure underthe Contractor's State License law forthe following reason(s):
By my signature below I acknowledge that, except for my personal residence In which I must have resided for at least one
year prior to completion of the improvements covered by this permit) cannot legally sell a structure that I have buttes an
owner -builder if it has rot been constructed in its entirely 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 Wet site: http/www.leginfo.ca.gcvfcal8w,htrnl-
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 ttiusiness and Professions 4anlcWe is In me and effect.LICENSE CLAS � LIC. NO.:EXP. DATE.%- �'' 9' CONTRACWORKECN 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 Wife Labor Code, for the performance of thework 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 this permit Is issued. My Worker's Compensation Insurance Carrier and
Policy Numger are: r
CARRIER
POLICY NUMBER
(alts SECTION NEED NOT BE CCMPtEMD IF THE PERMITIS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that inthe performance ofthe work for which this permit is issued, I shall not employ any person In any manner so Esta
become subject to the Worker's Compensation Laws of California. And agree that If I should become subject to the Worker's
Compensation provisions of Section 370D of the Labor Cade, l 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 ofthe compensation,
damages as provided for in section 3708 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 certitythat l 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 construction, and hereby authorize representatives of this county to
enter upon the above-mentioned property for inspection purposes.
7 :� 4, t L-,,, --/o t
PFFMITTEE NAME (PRINT
DATE
TYPE CONST
Scope of Work
# DWEL. UNITS # STORIES
OCC GROUP:
# BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFFII REM
Garage/Carport
Patio/Deck
Pool/Spa
Re -Roof
Commercial
Valuatean: Adj, Area:
WHITE—Department Copy, YELLOW — Finance Copy, PINK— Assessor Copy
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRF -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: PAID BY:p�
VALIDATION:
RECEIPT #3(0 T8. PAID BY: V I CCi� 8
VAL1f)ATION: LC—
WHITE—Department Copy, YELLOW — Finance Copy, PINK— Assessor Copy
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