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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
-y 21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027
,,,,,.,.�.,: FIRMLY
,mss ` BUILDING PERMIT APPLICATION wwwcityofdiamundbar.com building@diamondbarea.gov
JOB SITE ADDRESS 5 —Ta i at`rj; Cfr
APN Vita.VWT i' TRACT
OWNER @9}y° e_�
ADDRESS ;
CITY ZIP STEL. 10y'1-7Il
APPLICANT Diow TEL.
CONTRACTOR r (db 1
ADDR S
CITY I I i bA 00s , IP Ct77 'TEL. 4� f - )..T-,7
ARCH/ENG! 1
DESIGNER�� y
ADDRESS
CITY ZIP TEL,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the mason(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 statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter9) Commencing with Section
7000 of Division 3 of the Business and Professions Code] orthat he or she is exemptfrem licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the appllmntto a eivll penalty
of not more than five hundred dollars ($500).
O1, as owner of the property, or my employees with wages as their sole compensation, will do U all of or (_) portions
of the work, and the structure is not intended or offered for sale {Secffon 7044, Business and Professions Code: The
Contractors' State License Law does net applyto 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 forthe purpose of sale.).
U 1, as owner of the property, am exclusively conUaeting with licensed Contractors to construct the project (Section
7044, Rusiness and Professions Code: The Contractors' State License Law does not apply to an owner at property who
builds or improves thereon, and who contractsforthe projects with a licensed Contractor pursuanttothe Contractors' State
Ucerse Law).
U I am exempt from licensure under the Contractor's State License law for the following reason(s):
Date: Sign:
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 com rletlon of the improvements covered by this permit,[ cannot legally salla 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 this application is
submitted or at the following Web site: http/www.leginfc.ca.gov/calaw.htnl.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 {commencing will Stiction 7000)
of Division S of the Business and Professions Code, and my license is In full ioreti and effect.
4ICENSE CLASS: LIC. NO,: �1
P. DATE CONTRACTOR:
ir WORKER'SCOMP ISATIO DECiARATIO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS,
I have and will maintain a Cer [ficath of Consent to Self -Insure for Workers Compensation, as provided by
Section 370D of the Labor Code, 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 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:
CARRIER
POLICY NUMBER
(TRIS SECTION NEED NOT BE COMPLETED IF THE PERMIT I7d,I
#Ir
D DOL AAS $100 OR tESS}.
I cerufythat in the performance ofthe work for which this permit is i lay any person in any mannerso alto
become subject to the Worker's Compensation Laws of Cal€fomi ould become subject to theWorker's
Compensation provisi ns 1 cion 3700 ofthe Labor Code, Ish I those provisions.
DATE,( `T PLICANT: f
WARNING: Failure to secure Worker's Compensation co erage is unlawful, Ind shall subject an employer to criminal
penalties and civil fires up to are hundred thousand dollars ($100,000), in addition to the cost 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 for
which this permit is issued (Sec. 3097, Civ. C.).
LENDER'S NAME:
LENUFR'S ADDRESS:
i
Icertify 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 buildingconstruction, and hereby authorize representatives of this county to
e alcove.. -ane tioned pr py,,ty nspedon purposes,
enter upe;
ERMUITEE NAME IN
-I
IGNATURE P R DATE
i
APPLICATION DATE: S� S 11—+
ISSUE DATE: I �� 1 \ PERI :
TYPE CONST,
P/C# rn \1 - 1 % 9'3
f13, \"i — 1 8 q 3
OCC GROUP:
Scope of Work
# DWEL. UNITS # STORIES
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126.�1
# BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Patio/ tick r:
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LL70-01/sl
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Valuatia
Adj. Area:
QUANTITY F DESCRIPTION
FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
3Co • ti +�
SMTP:
S�
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
io • O�
BASF:
PLOT PLAN:
70NING CLEARANCE:
4�{
TOTAL FEES
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPTS 5 f" - ) d PAID BY: CIL- I \ VALIDATION: S-Sr9
WHITE — Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy