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� � D£PARTMENT OF COMMUNITY&DEVELOPIv�NT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
'�%�^ BUILDING PERMIT APPLICATION FIRMLY
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
ADDRESS
APN LOT TRACT
OWNER'A f
I"7U,
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR-k3-, --e
ADDRESS YE� -7
CITY -J 1^v w-C ZIP TEL.
ARCH/ENG/
\
DESIGNER
ADDRESS
CITY ZIP
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE C RACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSION . DE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT.ALTER.IMPROVE. DEMOLISH REPAIR ANY STRUC
TURF. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUC RMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISI OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVI 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AN E BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT F PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOL($500)):
^I,AS OWNER OF THE PROPERTY.OR MY EMPLOY WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT I NDED OR OFFERED FOR SALE !SEC. 7044, BUTI-
NESS AND PROFESSIONS CODE.THE CONTRACT S LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THER,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES,VIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVER,THE LDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TION,THE OWNER-BUILDER WILL E THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF LE).
^I,AS OWNER OF THE P PERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PR T(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT PLY TO AN OWNER OF A PROPERTY WHO dUIIDS OR IMPROVES THEREON,AND
WHO CONTRACTSF SUCH PROJECTS WITH A CONT RACTOR(S I I ICENS ED PU RSUANT TO THE CONTRAC-
TORS LICENSE L
CJ I AM EMPT UNDER SEC. e.A PC. FOR THIS REASON
OWNER
LICENSED CONTRACTORS 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 FORCE AND EFFECT
LICENSE CLASS LIC. N0.Z
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D
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NTRAC
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I N VE AND WILL MAINTAIN A CERTIFICATE OF CONSE-F-INSURE FOR WORKERS'
PEN6.A
ROVIDED BY SECTIO F THE LABOR FOR THE PERFORMANCE
FOR
OF RK FOR yy,CH THIS PE 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 CARRIER A POLICY NUMBER ARE:
CARRIER--,�-�-"7.5,
POLICY NUMBER i�L��-"� • 7 CSC-�^'��f��
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMA
WORK FOR WH -THIS PERMIT ISSUED,I
SHALL NOT EMPLOY ANY PERSON IER SO AS T COME SUBJ YO TH
WORKERS'COMPENSATION LAWS IA.AND A E THAT IF I ULD BECOME
UBTRKERS'COMPISI OF SECTIO OF THE LABOR
ODE SH L FORTHWITH COMPLE ISIO���($$$
/
DATEAPPLICAN
WARNINGAILURE TO SECURE WORKERS'TION COVERAGE IS U FUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100.000). IN ADDITION TO THE CPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE,INTER ORNEY'S FEES.
ATTORNEY'S
CONSTRUCTION LENDING A-CY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH T ERMIT IS ISSUED(SEC 3097,CIV.C)
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE AD THIS APPLIC ON AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMPLY WITH ALL CITY A COUNTY ORDINANCES AND STATE LAWS RELATING TO BUI DING
CONSTRUCTION,AND HEREBY AUT RIZE REPRESENTATIVES OF THIS COUNTY TO ENTE�i UPON E
gBOVEMENTIO PROPERTY RINSPECTI OSES.
ERMITTEE NA T)
SIGNATURE ERMITTE DATE
APPLICATION 110 PERMIT(
P/C
DATE NUMBER#
//
ISSUE/TYPE OCC
�
DATE
CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR
SIDE/SIDE STREET RW^
SIDE
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Garage/Carport
LU
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Z Re-Root
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 2�, 50
COMMENTS
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy