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1� 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
'9 BUILDING PERMIT APPLICATION FIRMLY
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JOBSITE
ADDRESS' �i2 P<'
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOF i rC' P T a - �E t ' ' : 01-J
ADDRESS 3 1 "`sue � ° °41a � C) V'z i � —
CITY W t' evi t ,' - ZIP e " TEL ,. tee, -
ARCH/ENG/
DESIGNER 1` 2 F Ll LLr i L P
ADDRES
CITY I ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESAPERMITTOCONSTRUCTALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUG-
TURF, PRIOR TORS ISSUANCE, ALSO REQUIRES THE APPLICANT 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-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THEALLEGED.EXEMP-
TKON.ANY VIOLATION OF SECTION 7031.6 BYANYAPPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
ACPAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
'❑ L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITHWAGESAS 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
OFFEREDFORSALE. IF, HOWEVER THESUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAROF COMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ 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 NOTAPPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO'CONTRACTS FOA SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
❑ IAM EXEMPT UNDER SEC, B. 8 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 7000) OF DIVISION 3OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
: CENSE C SS ,° LIC. NO. "
r DATE' L�T a CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
-)HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE 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 CARRI R AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER'/ L
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(THISSECTION NEED NOTSE CoMPLETEDOFTHE PERMTTIS FORONE HU DREDDOLLARS($100)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD 8ECOME
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 3700 0E THE LABOR CODE, INTEREST, AND ATTORNEYS 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'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHAT THE ABOVE 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.
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PERMITTEEN E` LPRI f '
SIGNATURFOF PERMITTEE DATE
WHITE —Department Copy, YELLOW --Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
APPLICATI PERMIT P/C
DATE NUMBER # \
ISSUE TYPE OCC
DATE CONSTT, GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO, NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SQ. IT
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
U)
Garage/Carport
W
Patio/Deck
LL
Pool/Spa
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Re -Roof
Commercial
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Valuation ADJ.AREA
QUANTITY
DESCRIPTION
FEE
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wA
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. NO. PAID BY VALIDATION