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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 www.cityofdiamondbar.com building@diamondbarca.gov
JOB SITE ADDRESS 13&6 r✓<7Se,;7T w l ((6 cz LK
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OWNER MRL' C `�l.($,�•
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APPLICANT PX. TEL. ?,Z 7�2 9 % 2,-e'
CONTRACTOR a -e
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DESIGNER
ADDRESS
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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 item(s) (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 pursuant to the provisions of the Contractor's State License Law (Chapter 9) 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. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
U I, as owner of the property, or my employees with wages as their sole compensation, will do (_) 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' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or improves the property, provided that the improvements are not intended or offered for sale. If however, the building or
improvement is sold within one year of completion, the Owner -Builder will have the burden of proving that it was not built
or improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State
License Law.).
U I am exempt from licensure under the Contractor's State License law for the following reason(s):
Date: 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 of the improvements covered by this permiLl cannot legally sell a stror Lure that I have hnilt as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I underedand that a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or at the following Web site: http/www.leginfo.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 the Business and Professions Code, and my license is in full tome and effect.
LICENSE CLASS: Z LIC. NO.: 2 Z .
EXP. DATE: CONTRACTOR: c
WORKER'S COMPWSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's 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 Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are: 4�
CARRIER
POLICY NUMBER I , ` S p
(THIS SECTION NEED NOT BE COMPLETED IF 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 Worker's Compensation Laws of California. And agree that if I should became subject to the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, interest, and attorney's 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. Q.
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information is correct. I 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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PERMI AME T)
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SI OF ERMITT ATE
APPLICATION DATE: :2 �I P/C# ^®
ISSUE DATE: �'�I PERMIT#
TYPE CONST. OCC GROUP:
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Scope of Work f
# DWEL. UNITS # STORIES
S
If BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Lu
Patio/Deck
LU
LL
Pool/Spa
ZRe
-Roof
Commercial
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ED
Valuation: )d —'
Adj. Area:
QUANTITY DESCRIPTION
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
d 5o
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
2_00
BASF:
(• 0O
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPT # tO " * PAID BY: VALIDATION: A
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
A
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS: (-'r) PF -26,06W L-' P4-