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_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVIC DRESS
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax- (909) 561-3117 Building Inspection Hotline (909) 839-7027
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BUILDING PERMIT APPLICATION rvww.cityofdiamondbar.com building@diamondbarcaf.�gov '}
APPLICATION DATE: _ PIC#
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4 OWNER -BUILDER DECLARATION
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Cc I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasa n
oindicated below by the checkmark(s}, 1 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 statemenithat he or she
c,o is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 ai Division 3 0l the Business and Professions Code] or that he or she is exemptirom licensure and the basis for
`a the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars {$500}.
''I, as owner of the properiy, or my employees with wages as their sole compensation, will do f� all of or U portrens
® of the work, roil the structure is not intended or offered for sale (Section 7044, Business and PAOSS ons Code: The
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Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
�E or improves the property, provided that the improvements are not intended or offered for sale. It however, the building or
improvement is sold wiUrin one year of c
] ompletlon, the Owner -Builder will have the burden of proving that it was not built
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or improved far the purpose of sale.(.
(} t, as owner of the property, am exclusively contracting with licensed Contractors to canstmetthe project (Sec on
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7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
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who contracts for the projects with a licensed Contractor pursuanttotheContractors0
cc License Law.).
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� � 1 am exempt fro licensur under the Contractor's State 'tensa law I t following reason s:
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By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one
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year prior 10 completion of the improvements covered by this permit,l cannot legally 8011 a structure that I have built as an
a owner -builder if it has not bean constructed in its entirely by licensed contractors. I uAerstand that a
appllcabls law, Section 7044 of coPcationhis
x the Business and Professlom Code Is available upon re uest when this app
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CD suhmitted or at he following Web site: httplwww.leginio.ca.gOvicalaw.hum .
vLICENSED CONTRACTOR'S DECLARATION
mI hereby affirm under penalty of pe ju y that I am licensed undor, rovsions of Chapter 9(commencing with Section 7990}
of Division 3 of the Business and Professions Code, and my license is In full force and effect.
LICENSE CLASS: LIC. ND.:
CONTRACTOR:
EXP. DATE:
4 WORKER'S COMPENSATION DECLARATION
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4 I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF Ti FOLLOWING DECLARAT10N5:
o I have and will maintain a Certificate of Consent to Self -Insure for Worker's Cnmpensatlon, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
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V have and will mairdain Worker's Cnmpensatlon insurance, as required by Section 3740 of the Labor Code, or
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the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carter and
Policy Number are:
LU CARRIER
z POLICY NUMBER
(IRIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED D6LiAAS $100 DR LESS},
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=o I certifythatin the performance of the workforwhlch this permit is Issued. I shall not employ any person in any manner so a; to
o become subject to the Worker's Compensation Laws of California. And agree that it I should become subjectto the Worker's
Compensa9on provi ionspi Section 3700 otfhe Labor Code, I S Il iorihwith comply with those provisions.
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u„ DAT .,Zodr APPLICANT. ,
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WARNING: Failure to secure Worker's Compensation coverage is unlawfuk, and all sub]ect an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
rs damages as provided for in section 3708 of the labor code, interest, and allornaVs fees.
� CONSTRUCTION LENDING AGENCY
,LU 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 (Seo. 3097, Civ. C).
H LENDER'S NAME:
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LENDER'S ADDRESS:
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0. 1 certify that I have read this application and state that the above Information Is correct. I agree to comply with all city an
`z Courtly ordinances and state laws relating to building construclion, and hereby authorize representatives of this county is
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p enter upon the above-mentioned property for inspection purposes.
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PERMITTEE NAME (PRS INS '-�yv,,4
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ISSUE DATE: v PERMIT# :
TYPE CONST, OCC CROUP:
Scope of W rk
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lt,t2's a4 �' Bts� ;
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# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
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Garage/Garport
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PatiolDeck .�"+
LL Pool/Spa
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Commercial
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Valuation: Aril Area:
QUANTITY DESCRIPTION FEE
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CONSTRUCTION: 4 '
PLAN REVIEW: qO Eq.
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ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE: t
BASF:
PLOT PLAN:
ZONING CLI=PRANCE:
TOTAL FEES
COMMENTS:
PAID BY: �� VALIDATION:1V j)J
1ECEIPT # PAID BY: ' � VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK—Assessar Copy
COMMENTS: