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CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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OWNER-BUILDER DECLARAT
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
I CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
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ALSO REQUIRE
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S THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACT
ORS LI-
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CENSE LAW(CHAPTER 9(COMMENCING WITH SECTlON 7
000)OF DIVISION 3 OF THE BUSINESS AND PRO-
0 Pool/Spa
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
Z Re-Roof
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, 0
Commercial
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PR
F
0
ESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON
AND WH
0 DOES SUCH WORK HIMSELF OR HERSELF OR
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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-
Va.IUBtjOn ADJ
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CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAC-
QUANTITY DESCRIPTION FEE
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DATE OWNER H
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
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MENCING 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 CLASS LIC. N0.
DATE 8 r Z CONTRACTOR jz�w/�• d
WORKERS
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COMPENSATION DECLARATION' V
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATION . Z
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' S
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED LLl
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 W
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INSURANCE CARRIER AND POLICY NUMBER ARE:
OORqK S'COMPS T
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PLAN REVIEW 1 77
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CARRIER%�.14�Af
POLICY NUMBER �0 . 00
ELECTRIC
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMITIS FOR ONE HUNDRED DOLLARS(St00)ORLESS).
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PLUMBING/OG.
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
MECHANICAL/ . Ufa
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
INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
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DATE: ".
7
T-/_./APPLICANT:_j[�EIZ5 � �7 � L SMIP•Ur5
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
ENERGY P/C.. �
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
ENERGY PERMIT
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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
TOTAL FEES_2t
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
13
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
COMMENTS
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