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1*' ` � CITY UF I7IAM�ND BAR
�:�j ��"'^�� DEPARTMENT OE CQMMUNITY 8c DEVBLOPMBNT SERVICES
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(409)864-3195 Fax(9t?9)8b1-311?
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— — DATE CONST. GRQUP
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p ADDRESS � �� � � 2QNING SETBAGKS �
CITY 21P .TEL � � rt � FRONT � � �SW ❑
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+�r STATEMEM THAi HE OR SHE IS L�CENSED iH1RSUANT TO THE PPOV1910NS OF THE CONTRACTORS LI� �
� CFNSE lAW(GiAPTER B(C�MMENCMl6 WI7N SECTpN J60o}OF DIVlSI�N 3 OF Ti1E BUSINESS AND PHO� PooVSpa
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� ❑I.ASf1YMEROFhiEPROPEFTV,ORMVEMP40VEE3WITHWAGESA5THE1R5QLECAMPENSATION, � Commerafal
WILL Ofl THE VlORK,ANO THE$TRUC7URE IS NOT INTENpED OR OFFEflED FOR SAL.E(SFC,7a44,BUSI- J
NESS Ft�pflOFf3SiONS tXJDE:i}iE CONTMCTOR5 IICENSE UW OQES NC�T APPI.Y 7D AN OWNER Of
� PROPEfiTYN'Y109UILDSORIMPROYESTHEREON,AN�WHODOESSUCHWORKHIMSELFORHERSELFON �
CC TF1ROlMON HIS Ofl HER OWN EMPLOYEES,PPOVIOEb THAT SUCM IMPROYEMENTS ApE N071NTENb£D OR m
QQPrERE6FOt{SALE�FtOWEVER7NE8ULWNG�RiidGR6VEMENTt55IXDGY1'iHMONEVEhR6FC4MPlE
710N,THE OWNER•BUILDER WILL.NAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OP
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W CEN56 UW OOES NOTAPPLY TOAN ONMER OF A PFSOFERiY WHO BU!lOS Ofl IMARQYES TNEiiEbN.AND
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�.1[ LICENSED CONTRACTORS DECLARATION �
['.0 1 HEREBV AFRRM UNOER PENALTY OF PEiUURY THAT I AM LICENSED UNDEF PROVISKINS bF CHqpTER �
(,'[ q(COMMENCIN(i WITH SECTION 7000)OF DIYISION 80F THE BUSWF.SS AND PflOFE56lONS CADE,ANQ Z
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� WORKERS'GOMPEN5ATION DECLAHATION a -
� I HEREBV AFFIRM UNOER PENaLTV oF PE0.lURV aVE OF THF Fo�LOWING�ECLARAT�oNs: Z
� „_,_IHAVEANDWILLMAINTAINACEIiTiFlC,�TEOFCONSENTTOSELF�INSUFEFORWORKERS' _
COMPENSATION,ASPqOV10ED8VSECT70N37o00FTHELABORCODE.FORTNEPfPFORMANCE U ,,,,,_
OF THE WORK F4R WNtCH THIS PF.flMIT tS ISSUEQ. �
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w 1 NAVE AND WiLk.MAINTAIN WOpKEfl6'GOMFENSATIQN INSURANCE,AS REIXJIRED BY SECTION 1 �/j
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{�') SHAt,t.txii EMPCOV 0.MY PERSqN�7 ER SO AS TQ BECOME SUe.tECT T6 iHE
� WORKEHS'COMPENSATICIN LA CALIFORNIA,AND A@REE THAT IF I SHOULD BECOME ,,,. INSPECTION FEE
� 5U&IECT 70 THE WORI(EHS' PENSATbN PROVISIONS OF SECTION 3T00 OF THE LtyBO}7'
� COQE.ISHALiFOflTkWt COAiPLVWITHTHOSEPROV�SIqNS. ISSUANGE _,,,,,,, � -
4 �Y
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� WARNINO:F LVP O SECURE WORK£RS'CGMPEN5A(ION CAVEMC�E 19 UNIAWFVI.,AND SliALt 9E ENERGY P/C s��_ �
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� SUB.IECTANEMPl4YERTOCRHAINAIPENALTiESAN4GVI�FlNESUFTtlONEMJN6flEDTHOt/SFND ENERGYPERMIT '
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� I HEREBV AFFIPM UNbER PENALTV OF pERJURV THAT TNERE IS A CONSTRUCTION LENDING AGENCY
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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
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
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2Z919 GgM
ADDRESS-
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ADDRES
APN LOT TRACT
OWNER w
ADDRESS .2 0
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CITY 37 ZIP .TEL.
APPLICANT TEL_442Q Z44�
CONTRACTOR'ZL3
ADDRESS
CITY Ij ZIP EL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY_ZIP TEL.
OWNER-BUILDER DECLARATION
1 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 PERMIT TO 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 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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ LAS 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).
^ 1.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 NOTAPPLY 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. 8 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
B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CL
/^'
SS 16 LIC. N0. 7
/
J
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
ATION I RANCE C RIER AND POLICY NUMBER ARE'.
ISSUED. MY WORKER
S'PE
p
CARRIER[r yn
POLICY NUMBER
(MISSEC IONNEED NOT BE 03WETEDOFTHE PERMIT IS FOR J HJPDRED DOLLARS($l0o)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN NER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAW CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
���
SUBJECT TO THE WORKERS' PENSATION PROVISIONS OF SECTION 3700 OF THE 4aQR-
CODE,(SHALLFORTHWI COMPLY WITH THOSE PROVISIONS.
DATE:APPLICAN
WARNING: F LUR 0 SECURE WORK WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(9100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST.AND ATTORNEYS 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 THIS APPLICATION AND STATE THAT THE ABO INFORMATION IS CORRECT.
I AGRE PLY WITH ALL CITY AND COUNTY ORDINANCES AND STA LAWS RELATING TO BUILDING
UCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF jHfs'COUNTY TO ENTER UPON THE
ABOVE-MENTKONED PROPERTY FOR INSPECTION PURPOSES,-"'
PERM(AME(PW
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APPLICATI,Q N PERMIT
DATE G-/"ZG�G'1 2 NUMBER#
ISSUE TYPE OCC
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DATE�T
A CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF A DJ.AREANALUATION
SFR/ADD/REM
Garage/Carport 1963 '!jL'-
W Patio/Deck 00 (o
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LL Pool/Spa
Z Re-Roof
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5
m
Valuation 5 ADJ.AREA
QUANTITY DESCRIPTION FEE
U
I-
U
W
W
0
Z
OF S
-J
U
Z
W
i
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
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MECHANICAL FJ 1 r
INSPECTION FEE
ISSUANCE
IP
ENERGY P/C
ENERGY PERMIT'
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES tD V
2'/�Y
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CA
COMMENTS(
/J I
7 11
AO 0
z7 X
RECPT. N0. PAID BY VALIDATION WV
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
GATE
61
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