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CITY OF DIAMOND BAR �-
I i 1 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
'aeg' BUILDING PERMIT APPLICATION www.cityof'diamondbancom building@diamondbarea.gov
JOB SITE ADDRESS (T>11 D' y`"'��- 1✓r�e�
APN 1'' LOT
` L TRACT
OWNER_ ALeilG 1NAs
ADDRESS Za 1 Cq '
CITY f ZIP TEL. CD
APPLICANT TEL.
CONTRACTOR 1;64% C57 3
ADDRESS i 02 66166 is
CI ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL,
OWNER -BUILDER DECLARATION
I hereby aft€rm under penalty of perjury that I am exempt from the Contractor's State License Law for the reason(s)
indicated below by the checkmark(s), I have placed next to the applicable items) [section 7931.5, 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 Law (Chapter 9) Commencing with Section
7000 of Division 3 of the Business and Professions Cndej or that he or she is exempt ffom licensure and the basis for
the alleged exemption. Any vielatlon of Section 7031.5 by any applicant fora permit subjects the 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 their sate compensation, will do () all of or U portions
of the work, and the structure is not Intended or offered for sale (Section 7044, Business and Professions Cade: The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or Improves the properly, 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 Dwner-3uilder will have the burden of proving that It was not built
or Improved for the purpose of sale.).
U I, as owner of the property, am exclusively Contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Cade: The Contractors' State License Law does not apply to an owner of property who
builds or Improves thereon, and who contractsforthe projects with a licensed Contractor pursuanttothe Contractofs' State
License Law.).
(_) I am exempli itcensure under the Contractor's State License law for the following reason(s):
Date: Sign:
By my signature below I acknowledge that, except for my persona{ residence in which I must have resided for at least one
year prior to completion of the improvements covered by this permlt,l cannot legally sell a structure that I 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
j 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.legtnfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
iI hereby affirm under penalty of perjury that l am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license s in full and effect.
j LICENSE CLASS: LIC. NO.:
j
EXP DATE: CONTRACTOR:
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Sell -Insure for Worker's Compensation, as provided by
J Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued.
jr 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 Number are: P_
a CARRIER
POLICY NUMB R W
i
- (fHIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 ORLESS).
j I certify that in the performance of the work for which this permit Is Issued, I shall rot empley any person in any manner sc as to
become sub j t to the Workers Compensation Laws of fomla. And agree that It I should become subject to the Worker's
JCom ersatio ra Is n�f Section 3700 of the bar de, s If rthwith comply with those provisions,
Di I APRLICANT,_ -
WARNING: Failure to secure Worker's Compensation coverage Is unlawful, and shall subject an employer to criminal
7 penalties and civil fines up to one hundred thousand dollars ($100,000), in additlan to the cost of the compensation,
5 damages as provided for In section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
7 I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work tof
which this permit Is Issued {Sec. 3097, Clv. C.).. ) .
- LENDER'S NAME: ��/-•JJ�`
LENDER'S ADDRESS:
u
L I certliy that i have read this application and state that the above Information is correct. I agree to comply with all city and
county ordinances and state laws re ting to buikding cons action, and hereby authorize representatives of this county fo
J enter upon th®•above mentioned pop Pry for inspection purposes.
u!kill, 114Y4
PERMITTEE NAME {FOT� A n
n M E I
i= SIGNATURE DF PERM EE DATE
APPLICATION DATE: ► % P/C#
ISSUE DATE: �� PERMIT# : F9, ®-1
TYPE CONST. OCC GROUP:
,I
Scope of Work
do a c r .
# DWEL. UNITS # STORIES t # BEDROOMSJ.,
DESCRIPTION SQ. FT. FACTOR PSF
ADJ. AREAA/ALUATiON
SFR/ADD/REM
Garage/Carport
L
Patio/Deck
LL
L
Pool/Spa
zRe
-Roof
0
Commercial
e0
Vaivatiom D
Adj. Area:
QUANTITY DESCRIPTION
FEE
U
U
w
w
ca
z
a
U_
U
CONSTRUCTION:��-
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
r
_
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
E
BASF:
PLOT PLAN:
ZONING CLEARANCE:
��
TOTAL FEES
COMMENTS:
c�+
A1C: PAID BY:
RECEIPT# 9(a PAID BY:
VALIDATION:
VALIDATION: ann
WHITE — Department Copy, YELLOW -- Finance Copy, PINK— Assessor Copy
CITY OF DIAMOND
INSPECTION EC