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_�i�l.--- C1TY OF DIAMOND BAR '_t ,J�"�i`i`��z`�
, DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES �
_, 21825 E.Copley Drive PRESS
(909)860-3195 Fax(909)861-31 l7
'"'"j BUILDING PERMIT APPLICATION FIRMLY
o ADDRIESS Z��� �1 L � � DATE CATION 1 I NUMB R P!C
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� STATEMENT TH/T ME OR SHE IS UCENSEO PURSUANT Tp THE PROVISIONS OF 7HE CONTRACTORS LI.
� CENSE LAW(c%MAPTER B�(.JMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSVNESS AND PRO- u' POOVSpO
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NESS AND PROFESSIONS OODE:THE CANTRACTORS LIGENSE UIW DOES NOT APPLV TO AN OWNER OF
� VROPERTVWi�IOBUILD30RIMPROVESTHEREON.ANDNM11000E55UCHWORKHIMSELFORHERSELFOR m
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W OFFEREDFORSALEIF,HOWEVER,iNEBUIIDINGORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE
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O ❑I AM EXEMPT UNDEF',SEL. B.&P.C.FOR THIS REASON U
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�e[ LICENSED CON7RACTORS DECLARATION �j
CL I NEREBV AFFIRM UNDER PENAITV OF PERJURV THAT I AM UCENSED UNDER PROVISKKJS Of CHAPTER �
d 0�COAIMENCING WITH SEC110N T000)OF OIVISION 30F THE&USlNE55 AN�PROFESSIONS(:OOE,AND Z
X MY LICENSE IS IN FUIL FOPI:E PND EFFECT. m
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0 UCENSE USS �`F� LIC.NO. � �
V DATE I� I� CT'l_ CONTRACTOR a
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� WCiRKERS'COMPENSATION DECLARATION Q
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� I MEREB� M UN�EP PENALTV OF PERJURV ONE OF THE FOLLOWING DEQARATIONS: Z
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O I NAVE AND WILL MA NTAIN A CERTIFlCATE OF CONSENTTO SEIF-INSURE FOR WORKERS' _
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E WORN FOR\VHICH THIS PERMIT IS ISSUED. �
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W IHAVEFNDW�ILMAINTAINWORKERS'CAMPENSATION�NSURANCE,RSREOUIREDB�SECTION
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(,�} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECAME SUBJELT TO THE
� WOqKERS'COMPEN�iATKKJUW50FCALIFORNIAANDAGREETHATIFISHOULDBECOME INSPECTIONFEE
SU £CT'C ME WORKERS'COMPENSATION PftOVI510N50F SECTION 700 OF'HE LABO
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� SECTqN 3700 OF TNE LA60fl CAOE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
a CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
� I HEREBY AFFIRM UNDER PEIVALTV OF PERJURV THAT iHEflE IS A GONSTflUCTION LENDING AGENCV
d FORTME PERFORMANCE OFTME WORK'rOR WHICN TMIS PERMIT IS ISSUED�SEC.7097,CIY.C.).
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� IENDER'SNAME
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� I CEflTIFY 7NA71 HAVE READ THIS APPUCATION AND STATE THATTHE ABOVE INFORMIITION IS CORRECT. TOTAL FE ES ���
w 1 AQREE TO COMPLY WI�M ALL CfTY AND COUNTY ORDINRNCES JWD ST�TE UWS RELATVNG TO BNLDING �
� CONSTRUCTION,PND MEREbV AUTHORIZE REPfiESENTATIVESOF THIS COUNTV TO ENTER UPON THE
zABOYE-M�IONEO PROPERTv FOR�SPECTION PURPOSES. COMMENTS
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RECPT.NO. PAID BY VAIIDATION
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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^ '.M
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Z�>3I
L
l � vll
ADDRESS
APN LOT TRACT
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OWNER 3c VL
ADDRESS 3'
CITY D P�ZIP TEL. S
APPLICANT L Z1
CONTRACTOR
ADDRESS
CITY NJ LT-f\ZIP TEL. g Z-
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 REQUIRESA PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIRANY 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).):
^ 1,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 HIMSELFOR 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).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPI V TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDEF 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
LASS XJ LIC. N0.
E
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY M UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 HAVE AND WILL MA NTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
E WOR',OR 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'CO ENSATI INSURANCE CARRIER AND POLICY NUMBER ARE'.
CARRIER p'�0�
POLICY NUMBER �� 17
(TH5 SECTION NEE NOT BE CO&1PLE7ED OF THE PEFMT IS FOR ONE 14.04 RED DOLLARS(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 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 SOF THE LABO
CO
, 15H FORTHWITH COMPLY WITH THO PROVISION
DATE: It APPLICANT:
WARNING: FAILURE T 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.
CONSTRUCTlON 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.
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-M TIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
P�L
SIGNATURE OF PERMITTEE DATE
r-
APPLICATION
PERMIT P/C
I
DATE NUMBER
ISSUE TYPE 0 C
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
W Patio/Deck
LL Pool/Spa
Z Re-Roof
0 Commercial
D
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
.1
U
W
-J
W
0
-A I
Z
F
0
a
Z
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTALFEES Wf.
V
IV
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy