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CITY OF DIAMOND BAR `__----- ..
�� DEPARTMENT OF COIvIlvIUNTfY&�DEVELOPMENT SERVIGES �
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21825 E.Copley Drive
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CITY OF DIAMOND BAR
DEPARTME'�1T OF COMIvIUNTfY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
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ADDR
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APN LOT TRACT__
OWNER��,,;,g„� '
ADDRESS�i y� RJ�j,z.'
CITY��; .7/pJs; i4��'�,ja,�ZIP���TEL. 71t'�"-�/�"li
APPLICANT s5'UrM ��,'�, ��TEL.�a.i'3
CONTRACTOR-�i�/J�
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ADDRESS_�� �4��"!,'Y7_t�T;rl �11L
CITY ZIP�/-TEL.
ARC/ENG/
DESIGNER
ADDRESS
CITY ZIP � TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDEFI PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI�
CENSE LAW FOR THE FOLLOW ING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANV 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 CONTRACTORS LI-
CENSE LAW(CHAPTER 0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESBIONSCODE)ORTHAT HE ORSHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOLATION Of SECTION 7031.5 BY ANV APPLICAN�FOR A PERMIT SUBJEC ti fHF APPLICANT TO
A CIVIL PENALTY OF NOT MORE: THAN FIVE HUNDRED DOLLARS(5500). )�
^ 1,AS OWNER OF THE PROPERTY,OR M V EMPLOYEE S W iTH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT IN i ENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS ANO PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NO�APPLY 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 N07 INTENDED OR
OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING .'HAT HE OR SHE DID NOT BUILD OH
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7006, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI�
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO d'JII DS OH IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
C I AM EXEMPT UNDER SEC._B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENAI-N OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS_-�_��_LIC. N0. 1, ��
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TE �5=� ^-�:L� -> CONTRACTOR'� �
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1 �
RH;ERS
COMPENSATION DECLARATION
�v.:
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAIMA,IN ACERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I NAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER i
((HIS SECTION NEED NOT E'�E CCMPLECED OF THE PERMIT IS FOF ONE HONORED CX]L1AR5 (5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANV 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
COD
E,IS
H
LL FORTHWITH COMPLY WITH THOSE PROVISIONS.
A
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DATE:
APPLICANT�
WARNING FAILURE TO SECURE WORKERS'COMP ATION COVERAGE IS UNLAWFUL,ANO SHALL BE
SUBJECT AN EMPLOYER TO CRIN.INAL PENALTIES D CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALLY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUEC(SEC. 3097,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 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 AL THORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE�MENTION ED PR
ERTY FOR INS
TION PURPOSES.
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PERMITTEE NAME(PRINT)
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SIGNA IRE P RMITT
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