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CITY OF DIAMOND BAR'
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE
ADDRESS V
a'
APN .LOT TRACT
OWNER ,
ADDRESS'
CITY a r € ZIP r ,TEL.
APPLICAt�1" " TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL
ARCWENG/
DESIGNER.'.} �' t
ADDRESS / gr
CITY;
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OWNER -BUILDER DECLARATION
I HEREBY. AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPTFROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC.7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH REQUIRESAPERMITTO CONSTRUCLALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC.
TUBE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THEAPPLICANF FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE'CONTRACTORS LI-
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSK)NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.E BY ANY APPLICANT FOR APERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($600).):
❑ I,AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITRWAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC, 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THEPURPOSE OF SALE).
LT 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLYTOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS W17HACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW)-
❑ IAM EXEMPT UNDER $EC. B. L P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 700D) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
1 HAVE AND WILLMAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_ I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED- MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(MISSEMONNEEDNOTBE COMP ETEDOFTHEPERMITIS FORONE HAMEDDOLLARS ($100)ORLESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER $O AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST ANDATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
J HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE M A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDER'S NAME
LENDER'SADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHEA13OVE INFORMATION IS CORRECT.
1 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 -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PRINT) -
SIGNATURE OF PERMTTTEE DATE
APPLICATION
PERMIT
P/C
DATE
NUMBER
# .-
ISSUE..(
TYPE
�p
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
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REAR
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SIDE/SIDE STREET
RW
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SIDE
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PROPOSED USE,/
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NO. DWEL. (- .,
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NO.
UNITS STORIES°
BEDROOMS
DESCRIPTION
SQ. FT.
FACTOR F'SF
ADJ AREANALUATION
SFR/ADD/REM
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'Garage/Carport
W
Patio/Deck
LL
'' Pool/Spa
ZRe
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Commercial
Valuation
ADJ.AREA
QUANTI
DESCRIPTION
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ENERGY P/C
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RETENTION FEE:
PRE-ALT FEE:
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TOTAL FE..,
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COMMENTS
RCPT. NO. PAID BY
VALIDATION
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WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy'GOLDENROD—File Copy, GREEN —Applicant's Copy