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CITY OF DIAMOND BAR����
COMMUNITY DEVELOPMENT DEPARTMENT
2166011 Copley DriYeSuite 140 _ _- _.. rFPRESS
(909) 860.3195 Fax (909) 861-3117 _ -
RIIILDING PERMIT APPLiC_Alnt-1N FIRMLY
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i OWNER 44d 444 4t UfQe'=
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APPLICANT
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ADDRESS 7.
CITY ZIP _ _ _ TEL.
ARCWENG/
DESIGNER
ADDRESS
CITY - ZIP TEL _ -
I.
OWNER -WILDER DECLARATION
1 HERESY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS T.I.
CENSE I." FOR THE FOLLOWING REASON (SEG MIA SUSINESSMID PROFESSIWSCOM' MYCITY OR
COUNTY WHICH ROWIRESAPERWTTOGONSIMOTALIER SIPROVF4WAI SH, ONREPAWANYSTR41('
TIRE. PRIOR TO ITS SSUANCF- ALSO RAS THE APPLICANT FOR SUCH PERM TO FRE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT UO THE PROVISIONS OF THE CONTRACTORS LI:
CERISE LAW (dMPTER 8 (OOMYEICWO YRTH SECTION TOM OF DIVISION *OF THE WSNESSA D PRO•
FESSIONS CODOOR THAT HEORSM ISEXEMPTTKFW:FROMANDTMERASE PURTIENI.E.W EXFYR
TION.ANYVICLATIONOFSECTION M IJI SYAM APPLICANT FORAPERWT SUBECTSTHEAPPLIGVITTO
ACTHANILPENAILTV OFNOTYORE THAN FIVE HUNDRED DOLLARS P ): .. - -
L AS OWNEROF THE PROMM. GT. MY EMPLOYEES MSTN WAG ES AS TFIED SOLE COMPEMSAr0K
WR100-TIE WOI K, AND US STRUCTURE S NOT INTENDED OR OFFERED FOR SALE (SEC. FOAL 11151 --
NESS AND PROFESSIONS ODDS THE CONTRACTORS LICENSE NAW DOES NOT APPLY TO AN OWNER OF
PROPERTY MWIOBUAASOR YPMWSTHEREON.AND WHO DOES SUW WORK HIMSELF OR HERSELF OR
TISIOUGHNSOR HE CIRM EMPLOYEES. PROVDEDTUJSUCH SWROVEMENTSARE NOT WENDED OR-
OFiERWFORSMESSHDWEVEATHEBULDNOORWFKPr. EIRSSOLDWITIWONEYEAROFCOMWLb
TION. THE OWNEWNI ER WILL HAVE THE SIINDEN OF PROVM TWd HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE} -
❑ L AS OWNER OF THE PROPERTY AMEXCLUSMELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PAaWCT (SEN: 701K BRI*86 AND PROFESSIONS CODE: TME CO TRACTOM u.
DENISE LAW DOES NOT APPLY TO AN DINNER OFAPROPWNVMIOBUILDS OR PROVES THEREOIL MIO
MOOC* TRACTSFOR5tK PROJECM"rrKACMMWTORMUCEPffEDKMWAMITTOTMOWTRMe
TORS LICENSE INN). -
AM EXEMPTUNDER BEC. a S P.C. FOR THIS REASON
DATE
UCENSED CONTRACTORS DECLARATION
LHEREBYAFFWM UNDER PENALTY OF PERJURY THAT I AM 0004M UNDER PROVISIONS OF CHAPTER.,
SMOIBiENCINOWITH SECTION TYRO) OF DIVISION SOF THEN 04EN AND PROFESSIONS CODL AND
MY LICENSE IS N PAL FORCE AND EFFECT.
LICENSE CLASS - LIC. NO.
DATE CONTRACTOR .
i HERESJAFR M UAER FENAITYOF PUUUW DKDF THE FMUN MIO DECLAMTTONS:
1 HAVE AND VILL MAINTAPACERTNNNITE OF CONSENT TOSW FOR WORKERS,
COMPENSATION. AS PROVIDED BY SECTION 3MOF THE LABOR OWE, FOR THE PERFORMANCE
OF TNEWCW(FOR WHO4 HS PERM" IS .
..1 MINIS AM WW. MAINTAIN WORKE1W COMPENSATION INSURANCE. As REDUWEDBY SECTION
STOO OF THE LABOR DOGE, FOR THE PERPORMAM E OF THE MAIL FOR WHICH THIS PERMIT IB
ISSUED. MY WON(EITS' COMPENSATION NSUMNCE CARRIER AND POLICY MAISERAM
CA MIER -
PoucYFNUErEq
(IN68ECIIONN�1NOf SEOOLIPIEf@OFTff PEMETBFORDNEISSaRFD00LLANSIMOgORLP8B1..
I CERTIFY THA LATHE PERFORMANCE OF THE MONK FOR WHICH THIS PERMIT IS ISSUEO.I
SMALL NOT EMPLOY ANY PERSON NAVY MAKER 50 AS TO BECOME SUBJECT TO THE
WORT(ERS' COMPENSATION LAWS OF CAUFOWNLAND AGREE THAT W 1 SHOULD BECOME
SWIECTTO THE WOwcES' COMPENSATION PROVISIONS OF SECTION 5700 OF TI/ELABOR
CODE I WALL FORINMTN COMPLY WITH THOSE PROVISIONS.
FIATS- APPLICANT; _
MPIMa 40: FALURE TO SECURE WORKERSCOMPENSATION COVERAGE S UNLAHFUL. AND SMALL BE
SUBJECT AM EMPLOYER TO CRIMINAL PENALTIES AND CIVIL MES U TO ONE HUNDRED THOUSAND
DOLLARS (SIKO L IN ADDITION TO THE COST OFOOMPWWION. DAMAGES AS PROVIDED FOR IN
SECTIONWOOFTHELABOROOOE NTERESCANDATTORNEY'B FEES. - ..
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFSMA UNDERPENALTYOF PERKILY GNAT THERE S ACONSTIMICTON LENM4AGEK.Y
FORTHE PRAFORMANCEOF THE WORK FORWHICHTHIS PERMITS ISSUED (SEC. wW. CIV. C.).
LENDERS NAME
LENDER'SADONESS -
ICERTiYTHATIHAYE TDHMDSTATE TTHE ABOVENADFIMATION S CORRECT.
(AGREE 70ALOTYAND COI1Ntt 8 STATE LAWS RELATING TO BUILDINGHEREBYAUTIIORME III PRE 7 CMMYDERERUPONTHE
A&7Y IDNEO PROPERTY FOR
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NUMBER_ *
REVIEW
ISSUE
TYPE OCC
DATE `
CONST._;GROUP,�
INSPECTION FEE
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ENERGY PERMIT
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COMMENTS
SIDE
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PROPOSED USE
NO. DWEL NO.
''NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF AW. AREAN UATKkI
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CONSTRUCTION
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PLUMBING ■ J�
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ENERGY PNC
ENERGY PERMIT
RETENTION FEE;-
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COMMENTS
RECPT. NO. PAD BY C4 Wr VAUDA710N
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