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_!,�` CITY OF DIAMOND BAR �
DEPRFLTMENT OF COMMUNITY&DEVELOPMENT SERVICES
a 216fA E.Copley Drive 5uite 140 ���.S"'�,.r r r'.�'" `� PRESS
������t BUII.DING PERMTT APPLICATION � �� FIRMLY
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NALL 60 THE WC1R7C,AND THE STRUCtURE IS NOF{N7ENOED OR OfFEAED FOR SME(SEC.�68d,BUSI� _J
NESS ANp vROFESSIONS Cd0E:7HE CON7a.ecTORS�ICENSE�Aw�oEs No7wPpLY 70 AN(?Y,rNEN OF Q ` —/T— �'L r\
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� TIOFI.THE OWNER�pUIIDER WILL HAVE TNE BUflDEN OF PROVING 7HAT HE QH SHE DI�NOT BL111D Oft _—_ _
IMPPpYE FOR THE PUflPOSE oF SALE).
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LL I HERfBY IIfFIRM UFJ6ER PEN,LLTY OF PERJUHY THAT i AM 4iCEN5ED UNDEP PROVISIONS OF CHAPTER Lyi �t_
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(� SHA�L NbT EMPLOV ANY PERSON IN ANY MANNER SUAS 70 BECOME SUBJECT TQ THE
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i CEftTIFV THAT i HAVE READ TIi15 APPIJCATION AND STATE THAT TNE ABOVE INFORMAI'ION IS COflRECT. I QTAL FEES
� i RGflEE TO COMPIY WlTH ALl ClTY AND CAtINTY ORDINANCES AND STATE tAWS RElAT7NG TO BUILD�NG �
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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
AODDRIESS> 3 5�f f�'1�V Sr�--J
APN
LQT TRACT �7 Z 7-7
F
OWNER 1
ADDRESS 1804 VON KARMEN S TE 2 0 0
CITY TPVTNE ZIPA2612 TEL. 949-797-4
APPLICANT TEL.
CONTRACTOR-SAMF.
ADDRESS
CITY ZIP TEL.
ARCWENG//I
DESIGNERF I 15��CP A J
I
ADDRESS
CITY 240 NE rz*M.L
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 REQUIRES A PERMIT TO CONSTRUCT.ALTER. IMPROVE. DEMOLISH,OR REPAIR ANY 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 Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT FIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED 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).):
^ I.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 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 YEAROF 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).
0 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 TOAN 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.).
^ 1 AM EXEMPT UNDER 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
Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS LIC. N0.
4
Iti 5
17593
DATE CONTRACTOR
jp 9300 F
--PULTE
WORKERS'COMPENSATION DECLARATION
I HER 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 SECTlON 37000F THE LABOR CODE. FOR THE PERFORMANCE
PF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTlON
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
INS
P
0
E
M
POLICY NUMBE�RACIFIC
CC
,T
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�pp
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L�
7
(THIS SECTION NEED ET'WE�PEf�NiIISFD41 OREXPIIS(>:1W
Z&
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 SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: 5-IO'I APPLICANT: -P-jLTE; HOMES
WARNING: FAILURE TO 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 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087.CIV.C.),
LENDER'S NAME
NONE IPULTE)
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I 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-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITT
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SIGNATUIIAOFPERMITTEE,DATE
APPLICATION 3� I PERMIT I ^�P/C/� 7 I
DATE NUMBER V # ((_..�4 1
ISSUE G I.1
OCC
;�'TYPE
DATE J '
GROUP
ONST.
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