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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
LI
PRESS
FIRMLY
JOBSITE
ADDRESS'
..�1
API LOT
TRACT
OWNER i�
ADDRESS
CITY ZIP t 1S TEL
APPLICANT TEL
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER. IMPROVE, DEMOLISH,OR REPAIR ANY 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 9(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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
D I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
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 HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF 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).
D I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE'.THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE 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. NO
DATE CONTRACTOR
WORKERS'COMPENSATION 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 WORKERS'
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 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 AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(01415 SECTION NEED NOT BE COMPLETED OF 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
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,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT.
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN 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
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.C.).
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
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE DATE
PERMIT
/C
APPLICATION 25 a I
DATE UMBER 1
N
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED U_SF_T% rt?V� (Zii' 11 C I
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UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
Garage/Carport
LLI Patio/Deck
Pool/Spa
Z Re-Roof
Commercial
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
U
cr,
t-
U
w
LU
C
CD
J
Q_
Z
0
w
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE NOY
ISSUANCE
SMIP 1
U
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT EE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
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CITY OF DIAMOI�BAR�'
DEPARTMENT-OF COMI�tUNITY
21825 E Copley Drivc'�'-�" "" ,
(909it60-3195Fax(909)8�1-31i7
BUILDING PER1rIITAPPLICATiON
ADDRESS,
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s
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL
APPLICANT TEL
CONTRACTOR�", ' �
ADDRE S•
CITY a -ZIP�TEL
ARCHJENG/
DESIGNER�� �' '
ADDRESS �
CITY ZIP TEL
OWNER-BUILDER DECLARATON!
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FTLOM THE CONTRACTORS U-
CENSE UWFOR THE FOLLOWING REASON(SEC. 70.37.5 BUSINESSAND PROFESSK>r19 CODE ANYCITYOR
'CWNTYWHK7i REOUIRESAPERMITTO CONSTRUCT,ALTER IMPROVE, DEMOUSH,OR REPNRANVS7TiUG
TL1RE PAIOfI TORS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMP-Tlp FiIEA.B10NE0
STA7EMENT�7HAT HE OR SHE 6 UCENS£D PURSUANT TO THE PROVISIONS OF 71iE OONTRACTON3LT-
CENBE UW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF 111E BUBNIESSAI'0171TY
FESSKNJS CODE)OR YHATHE OR SHE IS E7LEMPT 7HEREFROMANO THE BASIS F'Oq 7T1E/d.L40H1EXBAp.
TKNI.ANY VK)IATKXI OF SECTION 7091;68YANYAPPLICMfT FOR APERMIT 3UBJEC78 j'!�T0,
AGVq_PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(L5001•k..... •:
^LAS OVCNEROF THE PROPERTY,OR MY EMPLOYEES WITHWAOESASTHEIR 801E
WILL DO THE WORK.AND THE STRUCTURE Iv NOT INTENDED OR OFFEREp FOR Su a �EC
i-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOEB NOT APPLY TONW OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO DOES SUCH WORKMMSEIFOR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOVYEVER 7NE BUILDOVGdi aAPROVEMENi IS SOLD WffFMN ONE YEAROF CdIPLE-
iTON,THE OWNER-BUgDER WILL HAVE 1HE BURDEN OF PROVING THAT ME OR 9HE OQ).NOT BUILD OR
aIPROVE FOR THE PURPOSE OF SALE).
^ L AS OWNER OF THE PROPERTY,AM EXCLUSNELY CONTRACTING WTM LX:ENSED
CONTRACTOR9
TO CONS7RUCf THE PROJECT(8EC. 70N. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW GOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BLINDS OR IMPROVES THFJiEON,�AND��
WHOCONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LK:BISED PURSUANTTOThIECONTAA4
TORS LICENSE UW.). � -.
'�„ �I AM IXEMPT UNDER SEC. �B. i P.G FOR T}ILS REI�SON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
(HEREBY AFFIRM UNDER PENALTY OF PERURY THAT LAY LICENSED UNDER PROVISIONS OF CHAPTER
9(ODMMENCOIG WRH SECTION 7000)OF ONISKKd J OF TFIE.BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE LS W FULL FORCE AppND EFFECT-
�T'SPC .. UC. No. � ..
LICENSE CU
SS �
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CONTRACTOR
I WORKERS'COMPENSATION CLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOW W(i OECLARATTONS: -
I HAVE AND WILL MAINTAIN A CERTIFIGTE OF CONSENT TO SELF-INSURE FOR NORKERg ..
COMPENSATION,AS PROVIDED 8Y SECTION 3700 OF THE LABOR CODE,FOR THE PEIiF'ORMANCE
OF THE WORK FOR WHiGI THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAVI WORKERS'COMPENSATKJNLNSURANCE,A9 REWIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATKJN INSURANCE GRRIER AND POLICY NUMBER ARE:
CARRIER�-t•� .
POLICY NUMBER-
(TFLBSECIIOPINEEpNDTBEOp.FLETIDOFTFE PEF11�7<T S FORONE kiIDREDDOLLAit6(>;lOD)ORLP56�
�I.CERTIFY THAT WTHE PERFORMANCE OF THE WORK�FOR WHICH THIS PERMRf6186UED,t
.'SHALL NOT EMPLOY ANY PERSINI W ANY MANNER SO AS TO BECOIAE SUBJECT TO THE
• ��WORI(ERS'COMPENSATION UWS.OF CALIFORNIA,AND AGREE THAT K 191pIAD BEODMfi
��•gUBJTSTTO THE YN]i0(ERS'COMPENSATKNJ PRDVaiIONB OF 8EOTION 87000E TFIE LATKIR
�. CODE,1 SHALL FORTHWRH COMPLY WITH THOSE PRONSIONS .ar,
DATE: r*' " �'4"'�APPLICANT: �-,,,,,�� � �t' ,
WARMN4 FAILURE TO SECURE WON(ERS'COMVE
TION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECTAN EMPLOYER TO CRaA0JA1. PENALTIESAND GYILFINE9 UP TO.ONE HUNDRED 17K)USAND
OW.ARS(1100,0001.W ADDITION iD THE cOSTOF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3701 OF THE LABOR CODE,WTEREST,AND ATTORNEYS FEES.. -
CONSTRUCTION LENDING AGENCY
I HEREBY AFFWM UNDER PENALTY OF PERJURY 1HAT THERE IS A CONSTRUGTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WON(FOR'A'HICFf THIS PER4UT IS ISSUED(SEC. 30W,GV.C.I.
LENDER'S NAME.
LENDERS ADDRESS .
I CERTIFY THAT 1 HAVE READ THIS APPLICATKJN ANO STATE THAT THE ABOVE INFORMATION 07 CORRECT
(AGREE TO COMPLY WYTN ALL CITY AND COUMY ORDINANCES AND STATE UWS REUTTNG 7D BURDW6
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATNES OF THIS COUNTY 1D ENTER UPON THE
ABOVE) ED PROPERTY FOgINSPEC PURPOSES
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COMMENTS
RECPT. N0. .. PAID BY R�VAtaDAT10N•
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-Flb Copy,GREEN-A(.iplk�rM's Copy