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CITY OF DIAMOND BAR � ( }-+ �`��-E�''(_,
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21660 E.Copley Drive Suice 190
(909)860-3195 Fax(909)861-3117 PRESS
���'� BUILDING PERMIT APPLICATION FIRMLY
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o ADDRESS 1440 Bridgegate DATE �� NUMBER � ��
c� ISSUE TYPE OCC
� APN L�DT TRACT DATE CONST. GROUP
p OWNER Trenton COF"
o ADDRESS I S IY@ V ZONING SETBACKS
� CITY � ZIP 90036TE�. 3. . $ 3 FRONT RW ❑
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J SECTION 3]OB OF THE U&JR CODE,INTEREST.AND ATTORNEI"5 FEES. RETENTION FEE:
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CITY OF DIAMOND BAR��C�� �;��N
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
ate
1440 Brid
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9
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ADDR
ESS
APN LOT TRACT
OWNER Trenton Cor
ADDRESS 5 7 I S Ire V
CITY�ziP 90036 TEL. 323.936.8
APPLICANT TEL.
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t� ��
CONTRALTO
ADDRESS
cITY�r n a e zIP 9120r�L, �yy-�s�li
ARCH/ENG! �t'
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS ANO PROFESSKNS CODE: ANV CITY OR
COUNTY WHICH REWIRESA PERMRTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE.AL50 REQUIRES THE APPLICANT FOP SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER Y(COMMENCING WITH SECTK)N 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT hIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TKXi.ANY VIOLATKk! OF SECTION 7037.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).):
^ 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSA7KNJ,
WILL DO THE WORK,ANO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7014, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERT�/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, HOWEVEO.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).
^I,AS OWNER OF THE. PROPERTY.AM EXCLUSNELV CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70M, 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 CONTRAG
TORS LICENSE LAW.).
^ i AM E%EMPT UNDER SEG. B.f P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTKNJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS G�"?L" LIC. N0. �-� --ss T
DATE�,/�4C,, �,-��L%9�CONTRACT���C
i
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATKNJ,AS PROVIDED BV SECTION 3100 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH TH15 PEP.MIT IS ISSUED.
�. I HAVE MID WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOH THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
����i ���
CARRIER
POLICY NUMBER_�;� �j �/•�
T
r.L
RMfT IS FOFi ONE FO.JhiXiED OOUPRS(EtOq OR LESSL
THE
PE
(IRIS SECiXXJ NEED N07 BE OOMPLEfED OF
1 CERTIFY THAT IN'ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSA7KNJ LAWS OF CALIFORNIA,ANU AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION SIGNS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FOFITHWITH COMPLY WI OSE PR VISIONS.
r
DATE:��/4^C� %�-;!;_�APPLICPjIf: � �� -� -_
/
5'COMPENSATION COVERAGE IS UNUWFUL, �� 5 LL BE
WARNING FAILURE TO SECURE WORKER
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDR SAND
DOLLARS(f 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 15 A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED(SEC. 3097,CIV.C.).
I
LENDER'S NAME
LENDER'S ADDRESS
�I CERTIFY THAT I HAVE READ THIS APPLICATION ANO STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE 70 COMPLY WITH ALL CITY AND COUNTY ORDINANCES ANO STATE UWS RELATING TO BUILDING
�CONSTRUCTION,AND HEREBY AUTHORI2E REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE
ABOVE-MENTKNIED PROPERTY FOR INSPECTKNJ PURPOSES.
1 .?
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I PERMRTEE NAII/E(PRINT)
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J�SIGNATUIiEE DATE
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