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CITY OF DIAMOND BAR
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 v""v.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESS SJ /a)- 3 ,Vi! ((rA') 001r.
APN LOT TRACT
OWNER "v,)
ADDR S 3113. 1 1, U/C
CITY iZI i Y& TEL. 5-1 _
APPLICANT ��1�w1 �TTEL. S 1(e 7
CONTRACTOR - ii C�
ADDRE S F �� Q ! vt (�l`
CITY r6tzkyi 6 ZIP TEL. 2 (i
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DESIGNER YJ+k 1C
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 reason(s)
indicated below by the checkmark(s), I have placed next to the applicable Itemjs) [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 pursuantto the provisions of the Contractor's State License law (Chapter9) Commencing with Section
7000 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. Anyviolation of Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty
of not more than five hundred dollars ($5410).
U 1, as owner of the property, or my employees withwages as thefrsole compensation, will do U all of or U portions
of the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' Sta€e License Law does not apply to an owner of properlywho, through employees' or personal effort, builds
or Improves the property, provided that the Improvements are not intended oroffered for sate. If however, the building or
improvement is sold within one year of completion, the Owner Ruilderwill have the burden of proving that it was not built
or improved for the purpose of safe.).
(U 1, as owner of the property, am exclusively contracting with licensed Contractors to construct The project (Sedoa
7044, Business and Profession Code: The Contractors' State License Law does not apply to an owner of property who
builds or improves [hereon, and who contracts For tie projects with a licensed Contractor pursuant to the Contractus' Slate
License Law.).
() I am exempt from licensure under the Contractor's State License law for the following reascn(s):
Data: 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 completion at the improvements covered by this permit,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
applicable law, Section 7044 of the Business and Professions Code is available upon request when this appncaton Is
submitted or at the following Web site: htiphwm.leglafo.ca.gov/calaw.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 lite Basin and Professions Code, a my llcens is In full force and effect. `
LICENSE CLASS: NC. NO.:
EXP. DATE: I CONTRACTO
WORKER'S COMPENSA 0 BE ATIDI
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF FO NG g€6 TIONS:
€ have and will maintain a Certificate of se e s� sure for Wo f s Compensation, as provided by
Sedan 3700 of the Labor Code, for the eA am of Dhe work to=
o ch Ibis permit is issued.
3 have and will maintain Worker's Compen than Iasurance,.asYequired by Section 370[1 of the Labor Code, for
the performan oft a wok for which th' permit is issued. My Wuker's Comp s tion Insurance Carder and
Policy Nu a ar : r
CARRIER r �r +epu
POL€CYNUMBER 4
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
1 certifythat in the performance of the work for Wch this permit is Issued. I shall net employ any person In any manner so as to
become subject to the Worker's Compansation Laws of California. And agree that If I should become subject to the Worker's
Compensation provisional Sedan 3700of the Labor Cede, I shall fedhwit h comply Mth those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shell subject an employer to criminal
penalties and civil Ones up 10 one hundred thousand dollars ($100,000), in addition 10 the cost of the compensation,
damages as provided for in section 3708 of the labor code, iotornt, and aftaneys 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:
LENDER'S ADDRESS:
I certify that I have read this application and slate that the above information is correct. I agree to Comply vdth all city and
county ordinances and slate laws r alirhg to building construction, and hereby authorize represenlaflves of this county to
enter upo the above-ree"Me d perly for inspecMm imposes,
PERM NAME (PRI l
SIGNA REOFPEPRIEE DATE r
APPLICATION DATE: ' /I I P/C#
ISSUE DATE: j � PERMIT# : f!p tq -` 09
TYPE CONST. OCC GROUP:
Scope of Work Vr1 �R
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1 .fes
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
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Pat€o/Deck '
LL
PooVSpa
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-Root
Commercial
Valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
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ca
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPT # PAID BY: VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS: