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1� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190 51
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
ADDRESS a/>9 J"3 N9l/BL/Al J-n.,V
APN LOT TRACT
OWNER lWLY ODD NDA
ADDRESS 4225 6I5AIIZ,2- CQ0e7_ 0e1(/F 'rL0
CITY CUWA.14 ZIP :TEL.
APPLICANT TEL
CONTRACTOR A i>
ADDRESS '
CITY �S'!'17A )l7 /t22 ZIP TEL Lr0 7C,4(i
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOILO'674 REASON (SEC, 7031.E BUSINESS AND PROFESSIONS COOS ANY CITY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRICT. ALTER IMPROVE, DE IOLISH.OR REPAIRANY STRUC-
TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE LS LICENSED PURSUANT TO THE PROVLSIIONS OF THE CONTRACTORS UL
CENSE LAW ICHAPTER I (CCMMENCCNO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED FXEMP-
TON.ANY V10lATON OF SECTION 7031.3 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (t500).F
0 L AS OWNEROF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. IOAA, BUSH
NESS AND PROFES' S COOS THE CONTRACTORS UCEhSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WINO BUIDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF CA
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE F. HOVYEVERIHE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLF-.
TION. THE OWNER -BUILDER WALL HAVE THE BURDEN OF PROYNG THAT HE OR SHE DU NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
❑ L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC 70u, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHOCONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS UCENSE IAWj
0 CAM EXEMPT UNDER SEC. B.1 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING MTN SECTION TOM) OF DMSION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE UC. NO. -^
DATE ��RRONTR,A�(IC7T�OR Nii
ff
WORKERS' COMPETJS lO DECIAA ilO
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
_I HAVE AND WILL MAINTAIN 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.
-1 HAVE AND WLLMA04AIN WORKERS' COMPENSATION INSURANCE AS I EOWRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WOOL FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS COMPENSATION WSIJRANCE CARRIER AND POLICY NUMBER ARE
CARRER
%L1 _21%OZ
POLIC'/MAMBER
MIS SECTION NEED NOT BE COMPLETED OF THE PEF11,ff IS MR ONE "DREDDOLLARS aID)ORLFS4
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N 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,1 SHAM FORTHWITH COMPLY WITH THOSE PROVISONS,
DATE APPLOANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CR JINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (F100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR N
SECTION 37010E THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFAM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WrZOR WHICH THIS PERMIT IS ISSUED (SEC. 30/7, C V. C),
LENDERS NAME
LENDERS ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS (ORRECL
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUDDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTAT OF THIS COUNTY TO ENT ER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PU ES.
PERW E LPRNT)
n
2'
SIC RE PEAma:Li;j DATE
APPLICATION PERMIT��1% Pic
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1 DATE NUMBER s
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE — -- -
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. F E
FACTOR PSF
ADJ. AREAIVALUATION
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Valuation _ ADJ.AREA
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DESCRIPTION
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TOTAL FEES 0/ D
COMMENTS
RECPT. NO. D BY VALIDATION
WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
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