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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
,w 21825 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027 PRESS
"i BUILDING PERMIT APPLICATION
JOBSITE L !!JJ - FIRMLY '
ADDRESS !� & 1 GL 'el/ 2 / APPLICATION
.. j j 1 ` (� PERMIT P/C
DATE ! NUMBER # �%� °�Z
APN LOT ISSUE OCC
TRACT DATE TYPE
OWNER l ty t� 5 fA CONST. GROUP
ADDRESS _S--d-11
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ZIP Q24 TEL.
APPLICANT
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CONTRACTOR
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CITY
ZIP TEL,
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DESIGNER _
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CITY
ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC.
TURE, PRIOR TO ITS 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 CONTRACTOR CENSE LAW (CHAPTER 8 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND S LD
LI FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS -
FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (E500).):
01. AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITHWAGES AS 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 NOTAPPLY 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 FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OFCOMPLE.
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ I, 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 OFAPROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. S. & P.C. FOR THIS REASON
DATE
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
B (COMMENCING WITH SECTION 7000) 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 OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37GO 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
1 700 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
(IRIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($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 I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS,
TE: APPLICANT:
k1BJECT
URE TO SECURE VIORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
MPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONEHUNDRED THOUSAND
,o0G), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
M UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.).
Y THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
UCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
1ENTIONED PROPERTY FOR INSPECTION PURPOSES.
I
(PRINT)
Copy,
2GC-
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE
PROPOSED USE
NO. DWEL.
UNITS
DESCRIPTION SQ. FT.
SFR/ADD/REM
W Patio/Deck
Ill
L- POOI/Spa
0Z Re -Root
® Commercial
Co
Valualion _
QUANTITY
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
It
NO. NO.
STORIES BEDROOMS
DESCRIPTION
ADJ.AREA
FEE
TOTAL FEES
COMMENTS
RECPT. NO. PAID BY
VALIDATION +
-Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Cobv