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CITY OF DIAMOND BAR `—'�/
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION - FIRMLY
JOBSITE
ADDRESS La' BlueMAJ AV
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACT _
ADDRE S
CITY 1_k-W� ZIP TEI_4)J D�JrII
ARCHlENG/
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 FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CRY OR
COUNTYWHICH WCH REQUIRESA PERMrrTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH,OR REPAIRANYSTRUC-
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 U
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS Is6m)*
❑ I, AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUST. -
NESS AND PROFESSIONS CODE, THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HISOR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER, THE BUILDNGOR IMPROVEMENT IS SOLA WITHIN ONE YEAROF COMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CADS: THE CONTRACTORS LI-
CENSE UW ODES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTAAP
TORS LICENSE UW.).
711AM EXEMPT UNDER SEC. -�^ B. & P.C. FOR THIS REASON
DATE OWNERS__ _
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEFUURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
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LICENSE CI 0,
Ip LIC. NO. SO_ :�-,--
DATE I �` CONTRACTOR __L I
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
—I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK ,1011 WHICH THIS PERMIT S, 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 WORKE}}$ COMPENSATION INSURANCE CAR IER AND POLICY Nl1MBER ARE:
(/�(� � 7
CARRIER
POLICY NUMBER`
(HMS SECTION NEED NOT RECOMPLETFDOFTHE REMO LS FOR ONE HUNDRED DOLLARS ($100) OR LFSSL
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 BF.COMF 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 II SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS,
DATE: S1 ___c APPLICANT. .�� -%+ I i
I
WARNING TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT ANN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTION 3706 OF THE LABOR CODE, INTE REST, AND ATTORNEY'S FEES.
J CONSTRUCTION LENDING AGENCY
i
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C,).
1
LENDER'S NAME
LENDER'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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.
C PEflMITT AME (PR_ If)? / j� (/
7 ✓
� SIGNATURE OF PERMRTEE GATE
APPLICATION /01
� f NPERMIT
U
DATE MBER
ISSUE TYPE OCC
DATE CONSTT, GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES - BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SFRIADD/REM
C0
Garage/Carport
WPatio/Deck
LL
PocVSpa
0
z
Re -Roof
QCommercial
-
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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U
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W
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CCL
Q
U_
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CONSTRUCTION
PLAN REVIEW -
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP 11 1171171
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
_
RECPT. NO.
ICA
PAIDBY - " VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, LSULutrNKULJ -HrI a copy, umcr:N—AppBDani5 copy
CITY OF DIMMOND
MSPECTION, RECORD
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