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� GITY OF DIAMOND BAIt
DEPARTMBNT 4F CGMMUNITY&DEVELOPMEN'I`SERVICES
w 21b6d E.Copley Ihive Suike 140
(909)&60-3195 Faac(909)861-3117 PRESS
'"�"' Bt3ILDING PERMIT APPLICATION �, ��, FIRMLY
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S7ATEMENT THAT HE OR SNE IS LICENSED PURSUANT TO THE PRDYISIONS OF THE CONTRACTORS L.b
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A ❑i,li50WNEROFTHF.PflOP£RTY,6flMVEMPI.OYEESWiTNWAGE5A5THHRSOLECQMPENSATIOIV, �OR51tiBtCi23
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PIiOPERTY WFIO BUILDS Oli IMPROVES TNEREON.AND NMO D06S SUCit WORK HIMuEIFOR NERSE6F OR
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IMVROVE WR 1HE PURPOSE Of SALEj.
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CEN$E UIW DpE$NC7T MPLY TO AN ONMER OF APPOP6RTV WNO BUILDS OR IMPHOVES THEREON,ANU
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� �HENE9Y AFF�RM UhDEfl PENALTV OF PERIURY TiiAT�AM IICENSEb VNOER PROVtSION$OF CSipATEfl �
(� f(CUMIMENCUI6 KtTH SF.CSK7fi 7AWj OF tNYi51PY 3 6F TMF eU5ME5S AND PROFESSIQNS CADE,AND �
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� 1 HEREBY AFFIRM UNOEH PEN,LLTV OF PERJURV pNE OF THE F9LLOWMG DECLARATIONS: Z
� _„_�NAVE AND VA41.MAINTAIH A CERTIFICt,TE OF IXNaSENT TO SECF-IN$URE FQR YlONKERS' a
IX,)MPENSATION,AS PROY14E6 8Y S£CTION 3Toli OF THE U180H GOQE,FOR THE PENFORMANCE U
Q OF TNE WOqK FOR 4MFIlCN TNIS PERMIT IS ISSUEA. �
ti �I H�VE AND WIIJ_MAINTAIN WORKERS'COMPEtJ$ATtON INSURANCE,AS REOUIR£O 9Y SECTpN
Q370o pF iHE tN30q WDF.FOR THE P£RF�Ru,tNCE Oc THE WpPo(F4R WHICH TH15 PERMIT I5
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� i CEATlFY TNRT IN THE PERI�OHMANCE OF TNE WORK FOR WHICH iHIS PERMIT IS ISSUED,1 MECHAN�CAL
� SNA11N0T EMPLqYANY PERSfXi INANY MANNER SO AS TO BECOME SU9JECT TO TH� � --'—"
�,/� WORKERS'COINPENSATION LAWS OF CA4IFORNIq AND AGREE THAT if t SNQULO BECOME tNSPECTfOhf�EE
� SUB,i£CTT{}TNE N+OqKERS'C06iPfNSAilOti RROYIS%tN54F SECTIQtJ 3Xao 4F THE UBqR — }
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� WARN�tiO:FAiLURE7G�5ECUflEtWRKERS'GOMPENSATtONCOYEftAGEISUNIAWiUL,ANCtSHA(J,BE ENERGYP/C � � _.._
� SUOJ[CT/rNEMPLOY[iRTQCHNA1NAlPENPLTIESANDCIVILFlNESUPTOONEHUIOREPTNOUSANO �NERGYPERMIT �
DOIURS(f100,Do0),IIJ ADDITION TO TNE COST pF COMPENSATqN.DAMA6ES AS PROV�DEO FOP W
� SECTION 3'!08 OFTNE LA@Oq CpDE,MTEREST.AN6ATTORNEY'S FEE5. RETENTION FEE:
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� GpN87RUCTiON LENpING AGENCY pRE-ALT FEE: _ „!_�„_
Q I NEREBV AFFIRM UNOEP PENA47V OF PERJUHY THRT TMERE IS ACANSTAUCTION LENpING AGENCY _J� ^5��{�,`,) �^}'�' ��""
FOR THE PEAFpiiMANCE OF iHE WORN FQR W4i1CH TMiS PEFMIT iS ISSUED{SEC.36eT,C!K C.j �t'�• ''r�—hi—�l.��.!
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p i A6REE TO CAMPLY WiTH N.L CITY fND COUNiV OROINpNCES AND STATE UK5 q£UTK�G ip gt/�p�NG l.?.L �''
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES
21660 E.Copley Drive SFrite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
-(',c.-Ass i t-S Af_�-In.: �Z� FIRMLY
ADDRESS Z3(�+Z�I(,�'r/""/�fll �1LS�"f-1}
APN LOT 3�-u+%TRACT S�-Z N�
OWNER�L/I•_I•'�7"1?Ct��'p
ADDRESS_�_lll yo 1/e+.i'A'tr'c.Yl
CITY__L L_V i/�_F'ZIP�Z� 1 Z TEL. � "/�-'�
APPLICANT
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CONTRACTOR�j �f{U/'nP-�%P
ADDRESS t,Xyu
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CITY Iva,�e n�ZIP �I Z6/Z-TEL��(�j��r7"CIO
ARCH/ENG/
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DESIGNER .�%
ADDRESSI '�
CITY;e�'ZIP�!'Z7G:x TEL. ��.��•-.S-i ('�'T��
OWNER-BUILDER DECLARATION
I HERESY AFFIRM UNCIER PENALTY OF PERJURY THAT i AM EXEMPT FROM THE CONTRACTORS LI-
CENSE I.A1F7 FOR THE FOLLOWING REASON(SEC. 703).6 BUSINESS AND PROFESSKNIS CODE:ANY CITY OR
COIINTY WHK]i REOUIRESIIPERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO 1T9 ISSUANCE.ALSO RF-OUIRES THE APPLKANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW(CHAPTER 0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFAOM AND THE BASIS FORTHEALLEGED E)(EMP-
TION,ANY VKXJ,TKIH OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF N07 MORE THAN FIVE HUNDRED DOLLARS(f6W). ):
^ 1,AS OWNER OF THE: PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATKNI,
WILL DO THE WORK,AND 1'HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70x4, BUSI-
NESS AND PROFESSK)NS(:ODE THE CONTRACTORS LICENSE LAW GOES NOT APPLY 70 AN OWNER OF
PROPERTY WHO BUNJDS OIL HIPBONES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THFK)UG11 HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMFIJTS ARE NOT WTENOED OR
OFFERW FOR SALE IF, HOFNEVER THE BUILDING OR IMPROVEMEM LS SOLD WfTHIN ONE YEAROF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPRCIVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF TH��E PROPERTY,AM EXGLUSIVF:IY CONTRACTING WITH LICENSED CONTRACTORS
70 ODNSTRUC7 THE PROJECT(SEC. 70u, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U-
CENSE UW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SU��i PRO.IECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTO THE CON7RA0
TORS DCENSE UW.).
�I AM EXEMPT UNDEER SEC. B. f P.C. FOR THIS RFI,SON
DATE OWNER
'LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISONS OF CHAPTER
� (COMMENCING MATH SECTKNi 7000)OF DIVISKNI 3 OF THE BUSINESS AND PROFESSK)NS CODE,AND
MY LICENSE LS W FULL FORCE AND EFFECT.
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LICENSE CUSS a
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DATE��'�J CONTRACTOR/�7�. !'fV II'�I'�S
WORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECORATIONS:
I HAVE AND WILL MAINTAIN ACERTIFICA7E OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LIBOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BV SECTKNJ
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
RS' PENSATKMI SURANCE CARRIER AND POLICY NUMBER ARE:
ISSUED. MV
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POLICY NUMBER_�/IJ t�TL � � � E J +73 J
(FRCS SECTlON NEED NOT E3E OCAPIFTF;DOFTHE PEPINT IS FOR ONE HUNDRED DOLLARS(f100)OR LESS).
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 70 THE
WORKERS'COINPENSATKKJ UWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATKkF PROVISIONS OF SECTKNI 37000E THE LAEK)R
V
SIONS.
ODE
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T FORTHWITH COMPLY WITH THOSE PR
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DATE: ��J-
APPLICANT:
f
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND
DOLLARS(f 100,000),O1 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDNIG AGENCY
C.).
ISS
UED(SEC. 3007,CIV.
FOR THE PERFORMIUiCE OF THE WORK FOR WHICH THIS PERMIT IS
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LENDER'SNAME� L9N �-� �V� ��� 'V�� ��T+-r
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTWG TO BUILDING
CONSTRUCTK)N,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTK)NED PROPERTY FOR INSPECTION PURPOSES.
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I PERMITTEE NAME(PRINT)
1
�SIGNATURE OF PERMIT7EE DATE
WHITE-Oepar[ment Copy,YELLOW--Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy