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_��_ CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
i 21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 RE$S
� '9^' BUILDING PERNQT APPLICATION FIRMLY
} JOBSITE /) /� �Z� , + / APPLICATION ' PERMIT �j� P/C ,
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w NO.DWEL. NO. � NO.
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HERFBV AFFIRM UNDER PENALTV OF PERNRV THAT 1 AM EXEMPT FROM THE CONTRACTORS LI• GdfB[JB/CBfPOff
W CENSE UW FORTFIE FOILOWINO REASON(SEC.7031.5 BUSINESSAND PROFESSIONS CAOE:ANY CITV OR (n
U COUNTYWHICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE.�EMOUSH,ORREPAIRPNYSTAUC � -
w TURE.PHIOR TO�fTS ISSUANCE,ALSO REOUIRES THE APVLICANf FOR SUCH PERMIT TO FI�E A SIGNED w Palio/Deck
STATEMENT THAT HE OR SHE IS IICENSED PURSl1ANT TO THE PROVISIONS OF THE CONTRAC70RS LI-
� CENSE LAW(CHAPTER V(COMMENCIN6 WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PRO� � PooVSpa
� FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� ' .
V TpN.ANYVIOLATiONOFSECT10N7031.68YANYAVPLICANTFORAPERMITSU&IECTSTHEAFPLICANTTO Z Re-Roof � ,
ACML PENALTY OF NOT MOHE THANFIVE HUNDRED DOLLANS(iSOD).):
❑I,ASONMEROFTHEPROPERTY,ORMYEMPIOYEESWITHWAGESASTHEIRSOLECOMPENSATION, Q
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Z VALL DO THE WORK,AND THE STRUCTURE IS NOT IHTENDED OR OFFERED fOR SALE(SEC.7011,BU51• J
� NESS AND PROFESSIONS CO�Ei THE CON7MC70RS UCENSE UW DOES NOT APPLV TO AN ONRJEH OF � -
— PROPEHTYVhiOBUILDSORIMPROVESTHEREON,PNDVMODOESSUCHWORKHIMSELFORHERSELFOq
Q iHROUGH HIS OR HER OHM EMF�OYEES,PROVIDED 7HAT SUp1 IMPROVEMENTS AHE NOi INTENDED OR . m �
� OFFEREDFORSALEIF,HOWEVERTMEBUILDINOORIMPROVEMENTISSOIDWfTHINONEVEAROFCOMFLE- .
z TION,THE�ON7JER�BUILDER WILL HAVE THE BURDEN OF PROVING 7HA7 HE OR SHE DID NOT BURD OR �
= IMP@OVE FOR THE PURP0.SE OF SALE). -
W ❑1,AS OWNER OF 7HE PROPEHTY,AM EXCLUSNELY CANTRACTM[i WfTH LICENSED CONTRACTORS .
� TO CONS7RUCT THE PR0.IECT(SEC.7os1,�BUSINESS AND PROFESSIONS CODE:THE CONTMCTOiiS LI• V81Uef1D0 ADJ.AREA . �
W CENSE UW DOES NO7APPLY 70AN OWNER OFA VROPERTV WHO BUILDS OR IMPROVES h1EREON.AND �
� 1rifOCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOP(5)I�CENSEDPURSUANTTOTHECONTRAC QUANTITY DESCRIPTION FEE �
� TORS IJCENSE LAW.).
� ❑I AM EXEMPT UNDER SEC. �8.8 P.G FOR THIS REASON
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTY OF PERJURY 7HAT IAMIICENSED UNDER PROVISIONS OF CHAPTER � --
d P(COMMENCINO WITH SECTION.7000)OF DIVISION 30F THE BUSINESS AND PFOFESSIONS ODDE,M1D Z
X MY LICEHSE 13 IN FULL FORCE AND EFFECT. /• m � � - � ,
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0 LICENSE/C�LASS{ � ^ 'UC.NO. �
U DATE (O�1 ����'i Z CON7RACTOR JI�'CY/��IYJ �� '� d - . . .
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PENALTY OF VERJURV ONE OF THE FOLLOWWG DEC[ARATqNS: Z � � �
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _
CAMPENSATION,AS PROVIDED BY SEC710N 370o OF 7HE UBOR CODE,FOR THE PERWRMANCE 'U.
Q �OF 7HE WORK FOR WHICH THIS PERMIT IS ISSVED. � ' '
w I NAVE AND WILL MAINfA1N WORKERS'�COMPENSATION INSURANCE.AS REOUIRED BV SECTION
Q 370oOFTHELABORCODE,FORTHEPERFORMANCEDFTHEWORKFORWHICHTHISPERMITIS ' � � �v
ISSUED.MV WOR 5'CA.M1PE�NSA710N IN�{,J�tANCE CMRIE AND POLICV NUMBER ARE: CONSTRUCTION
jCARRIER ��?'�'� � � PLAN REVIEW
� VOLICY NUMBER � °' .� �� � ELECTRIC
� (iH155E(,'fqNNFIDNOTBEODMP1.ETmOF71EP6Af(ISFORpiEFA1�DREDOql�fiS(5100)ORLESS) PLUMBING . . . . .
Z I CERTIFY THAT IN THE PERFOflMANCE OF THE WORK FOR WHipi 7HIS PERMI715155UE0.1 MECHANICAL�
C}' SHALL NOT EMVLOY ANV PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO7HE'
� WORKERS'COMGENSATION LAWS OF C/dIFORNiA,AND AGREE THAT IF I SHOULD BECAM INSPECTION FEE
SU9IECT TO THE WORKERS'COMPENSATION 7ROVISqNS OF SECTION 77000F TH �
� /�DE�I SHALL FORiMYI7H COMPLY WIT�H THOS.E�PROVI510 . � ISSUANCE • . C
p DATE:`� /����PPUCANT:� �'vt r!/"� �SMIP t ��_
J WARNIN6:FAILURE TO SECURE WORKERS'COMPENSATION CAVEMGE IS UNUWFUL,AND SHALL BE ENERGY�P/C .
� SUBJECTANEMPLOYER70CRIMINALVENALTIESAND�CIVILFWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLURS(S10o,000),IN ADDI710N 70 THE COST OF CAMPENSA710N,DAMAGES AS PROVIDEO fOR IN /�
� SECTION 370E OF TNE LABOR CODE,INTEREST,AND ATfORNEYS FEES. ' RETENTION FEE: �t �/
� CONSTRUCTIO,N LENDING AGENCY PRE-ALT FEE:^ ��
� 1 HEREBV AFFINM UNDER PENALTY OF PE0.JURY THAT THERE IS ACONSTRUCTION LENDINO A6ENCY (n`�`/7�n�
�FOR THE PERFORMANCE OF THE WORK fOR NTiIGi 7HI5 PERMIT IS ISSUEU(SEC.3097,CIV.CJ. ✓c� 1 �
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� I A6REE TO CAMPIV W17N ALL CT'ANO CIXINTY ORDINANCESAND STATE UWS REUTWG TO BUILDIN6
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENfER U70N iliE �
Z ABOVE-MENTIONED PROPERTY FOR INSPECTION VURPOs�s. COMMENTS � - �
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