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CITY OF DIAMOND BAR
1 I I 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.cityofdiamundbar.com building@diamondbarca.gov
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JOBSITEADDRESS i + t rTYF'E
CATION DATE 1�1a-71!� PIC# ®�
DATE: PERMIT#: —
APN LOT TRACT
CONST. OCC GROUP:
ADDRESS
SO. FT. FACTOR PSF ADJ. AREA/VALUATION
CITY �� :Y.�
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APPLICANT T
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CONTRACTOR
ADDRESS °'a
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CITY a a F is ZIP
OWNER -BUILDER DECLARATION e
2 -
I hereby affirm under penalty of perjury that I am exempt from the Contractor's S i nse L o e r o
Indicated below by the checkrnark(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 statement that he or she
is licensed pursuant to the provisions of the Contractor's State License taw {Chapter 9) Commencing with Section
700D 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 Section 7031.5 by any applicant for a permit subjectsthe applicant to a civil penalty
of not more than five hundred dollars ($500).
U 1, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or(_) portions
of the work, and the structure is not intended or offered for sale (Sector 7044, Business and Professions Cede: 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 Owner-Ruilder will have the burden of proving that it was not built
or Improved for the purpose of sale,).
11, as owner ofthe property, am exclusively contracting with licensed Contractors 10 construct the project (Section
7044, Business and Professions Code: The Contractors' State License Law does nut apply to an owner of property who
builds or improves thereon, and who contractsiorthe projects with a licensed Contractor pursuant tothe Contractors' State
License Law.}.
I I am exempt from licensure under the Contractor's State License law forthe following reasori
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 perri cannot legally sella tore 3 at I have built as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I on @ that a copy of the
applicable law, Section 7044 of Cne Business and Professions Cade is available upon requesiti is application Is
suhmltted or atthe following Web site: htiplwww.leginfo.ca.govlcalaw.hhnl.
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Olvislon 3 of the Business and Professions Code, and my license is in full force and effect.
LICENSE CLASS: 09-.) LIC. NO.: ---
EXP. DATE: f.. , CDMRACTORr J > —
6 WORKER'S CDNIPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DE"PJSTIONS:
I have and will maintain a Certificate of Consent to Sell -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Cade, 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 otihe Labor Code, for
the performance of the workfor which this permit is issued. Myorker's Compensation Insurance Carder and
Policy Number are: °
CARRIER --
POLICY NUMBER
(THIS SECTION NEED NOT BLCOMPLETED IFTHE PERMITIS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that in the performance ofthe work for which this permii Is issued, I shall not employ any person in any mannerso roto
become subject to the Worker's Compensation Laws of California. And agree that di should become subject to the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those pmvislons,
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 370B of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there 1s a Construction Lending Agency for the performance of the work for
which this permit is issued (Sec. 3097, Civ. C.).
LENDER'S NAMF:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information Is correct. I agree to comply with ail city and
county ordinances and state laws relating to building construction, and hereby authorize representatives ofthis county to
enter upon the above-mentioned property for inspection purposes.
PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
[ ; 11
Scope of Work
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION
SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SIF DD EM
GaragelCarport
atio eck
Pool/Spa
Re -Roof
Commercial
V,1. 11 52: �- t 1 Adj. Area:
WHITE Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
QUANTITY
DESCRIPTION FEE
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WHITE Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
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