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�,�`, CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Faz(909)861-3117
BUII.DING PERMIT APP�ICATION
JOBSITE
ADDRESS�'����� ��N�ON VIEW
APN LOT�TRACT
OWNER iJn/I vhi' :n! 1/)�'�/,� �mPMc n/
ADDRESS�:S$N A S'fA,�/N H �-'d'-2"
CITY y� LG�=�ZIP�TE�.
APP�ICANT_�G� Mt�GhlAN/CALL. 1-
CONTRACTOR_��--M E c'/��/.� NI �AA L Cs�,I i•-�°
ADDRESS 2�i1s 5"'
CITY R-�f 4'�FN'T�.ZIP TE�. �-
ARCWENGJ
DESIGNER
ADDRESS
CITY ZIP TE�.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE tAW FOR THE FOL�OWING REASON(SEC. 7031.5 BUSINESS AND PROFESSONS CODE:ANY CITY OR
COUNTY WHHxl REOUIREE�A PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMOLISH,OR REPAIRANY STRUG
TURE, PRgR TO 1T3 ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE�AW(CHAPTER 9(ix)MMENCINO WITH SECTK)N 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSgNS CODE)OR THAT HE OR SHE IS EXEMP77HEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TK)N.ANY VIOLATION OF SECTION 7031.5 BV ANV APP�ICANT FOR A PERMIT SUBJECTS THE APPI.ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�P,RS(f500).):
^I,AS OWNER Of THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044,BUSI-
NESS AND PROFESSKMIS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WMO 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, HD�NEVER THE 6UIIDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMP�E-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^ l,AS OWNER OF TH E PROPERTY,AM EXC�USIVELY CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PRO.IECT(SEC. 7011, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE(AW DOES NOT APP�Y TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON
AND
WHO CONTRACTS FOR SUI;M PRO]ECTS WITH A CONTRP,CTOR(S)�ICENSED PURSUANT TO THE CONTFUG
TORS DCENSE�AW.).
^ I AM EXEMPT UNDf:R SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECIJaRATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT 1 AM�ICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTON 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
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LICENSE C�P,SS
LIC
NO
DATE�(T� < <�CONTRACTO
WORKERS'COMPENSATI D RATI
1 HEREBY AFFIRM UNDER F'ENA�N OF PERJURY ONE OF H �LOWING D(ARATIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE(ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOFI WHICH THIS PERMIT IS ISSUED.
��
�' � I HAVE AND WI�L MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS
ISSUED. MV WORK ElRS'COMPENSAT INSU��/C'f�CE CARRIER'{}
1D POLICY NUMBER ARE:
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CARRIER�"�� 1 'G
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POLICY NUMBER_�I°'/_p! N', �N 1YI�7 r t� �__��p
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(DtLS SECDON NEED N078E NAlP�EfED OFTHE PERMIT IS FOR ONE HUNDRED DO�LARS(S1L
Oo)OR�ESS).
1 CERTIFY THAT IN'THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUB]ECT TO THE
WORKERS'COMPENSATKN LAWS OF CALIFORNIA,AN GREE THAT IF I SHOULD BECOME
SUBJECT TO THE V/ORKERS'COMPENSATIO VIS NS OF SEC ION 37000E THE�ABOR
CODE
SHAL�RTHWITH COMPLY WITH
P
S
R VIS NS.
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DATE:
N�
� APPLICANT: �
WARNING FAILURE TO SECURE WORKERS'C EN ION COVE E IS UN�AWFUL,AND SHAL�BE
SUB]ECT AN EMPLOYER TO CRIMINA�PENALTIE CIVI�FINES TO ONE HUNDRED THOUSAND
DOL�ARS(5100,000),IN ADDITION TO THE COST OF MPENSATIO,DAMAGES AS PROVIDED FOR IN
SECTON 3708 OF THE�ABOR C00 E,INTEREST,AND ATfORNEY'S EES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER P ENALTY 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
1 CERTIFY THAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATKN]IS CORRECT.
I AGREE TO COMPLY WITH,I�L C�TY AND COUNTY ORDINANCES AND STATE�AWS RE�,4TING TO BUILDING
CONSTRUCTION,AND HERI:BV AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
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ED
PROPE:RTV FOR
INSP
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PERMII-('EE NAME(P�T)
SgNATURE OF ERMITPEE-.. D TE
WHITE-Department Copy,YE�LOW-Finance Copy, PIN
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PRESS
FIRM�Y
CITY OF DIAMOND BAR
INSPECTION RECORD
IN�GTtON
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DATE
INSPECTOR