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�I CITY OF DIAMOND BAR
i DErARTMEIVT OF COMMUNITY & DEVELOPMENT SERVICES
" 21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESStr
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OWNER Yh �� pyNc
ADDRESS S.
CITY 9, Z A' ZIP
APPLICANT P 6 Va L 04 [ate TEL.
CONTRACTOR
ADDRESS
CITY_ TW L J171 rZIP TEL.LIT
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DESIGNER
ADDRESS 2
CITY ti' O F ZIP Q i 701TEL — $
OWNER- UILDER DECLARATION
I hereby affirm 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 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 statementthat he or she
is licensed pursuant to the provisions ofthe 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 exemptfrom licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicantfor a permit subjectsthe applicantto a civil penalty
of not more than five hundred dollars (S500).
CJ i, as owner of the property, or my employees with wages as theirso€e compensation, will do (,U all of or(-) portions
of the work, and the structure is not intended or offered for sale (Secilon 7044, Business and Professions Code: The
Contractors' State License Law does not app€yto 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 -Builder 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 owfler of property who
builds or improves tbereor, and who contracts for the projects with a licensed Contractor pursuant 10 the Contractors' State
License Law).
L_ 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, excel my personal residence In which I must have resided for at least one
year priorto completion of the improvements covered by this perni 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
applicable law, Section 7044 of the Business and Professions Code is available upon request when ibis application is
submitted or atthe following Web site: httplwww.leginto.ca.govlcalaw.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 force and effect.
(CENSE CLASS �15 LIC. ND.: 61 � -3 3 40
P. DATE: WS/ CONTRACTOR: , :r C 77"I 11 ��` .Y1R f, ,
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 Self -Insure for Worker's Compensation, as provided by
Section 3700 ofthe Labor Code, for the performance ofthe work forwhich #his permit is issued.
Dhave and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance ofthe work for which this permit Is issued. y Worker's Compensation Insurance Carrier and
{ Number are -
CARRIER
}' POLICY NUMBER
{THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS.
I certifylhat in the performance of the worl which this permit is issued, I shall not employ any person in any manner so a; to
become subject to the Worker's Compensation Laws of California. And agree that if I should become subjeotto the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthi comply with those proAsiors.
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 ($100,000), in addition to the cast of the compensation,
damages as provided for in section 3708 of the labor code, Interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work tar
which this permit is issued (Sec. 3097, Civ, C.).
LENDER'S NAME:
LENDER'S ADDRESS:
i
I certify that I have read this application and state that the above Information Is correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
enter upon the above- ones property for inspection purposes.
6,
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ERMITT£E
1 GNATURE OF PERMITTEE DATE
PRE&,
FIRMLY
APPLICATION DATE:P/C# P9 011-7
ISSUE DATE: l Iff %i 1 j40 PERMIT# : Z, l (=- —
TYPE CONST. OCC GROUP:
Scope of Work "C -Los y_ �Tn�
# DWEL. UNITS # STORIES # BEDROOMS
D O SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR i REM
Garage/Carport
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LL Pool/Spa
Re -Roof
O Commercial
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Valuation: t i Adj. Area:
QUANTITY DESCRIPTION FEE
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$
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CONSTRUCTION: 4,
PLAN REVIEW: I e W7
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE: �.
Si Edn
ENERGY P/C: -f-4 &
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF: (_
PLOT PLAN: -
ZONING CLEARANCE:
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TOTAL FEES aJ ► 'Vo
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPT # PAID BY: �, 3 s VALIDATION:
WHITE — Department Copy, YELLOW —Finance Copy, PINK—Assessor Copy
Pial;
1"KEOURNIZE
COMMENTS: