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_ �,� CITY QF I}IAMOND BAR (j
4 DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICBS t
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t�os}a�o-sl�s��t�a abt-a i�� PRESS
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� WORKERS'CQMPENSA710N DECLARATION � ��, u
� I HEREBYAFFlHM UNDEii PENALTV OF PERJURY bNE OF THE FOLLOWMG OFCLAPATIONS:
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� �I FUVE ANU W�1,6 MAMT�IIN A CERTtF�CAT�OF txJNSENTTO SELFINSUAE FCR WORKERS' 2 � v� ! �,,.
� COMPENSATK?N,�5 PROVIDED BY SECTICNJ 37W OF THE LABOR CI:JDE,FOR TH@ PERFORMANCE U t
OFTHE WOfiK FOR WHIGN TNiS PERMiT 1$t55UED. � �'�"" �
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SUBJECT t0 THE WqRKER6'COMPENSA710N PR�VISIONS OF SECTION 3700 OF THE LA90R � �/
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DOI.URS(i Wo,000).IN I�DITION Tq THE CoST OF COMPENSATION,�AMAGES AS PHOVIOED FOR IN ��
sSECFION37oeQFTMELABPRCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: ^„��,,,, , ,
a CONSTRUCTIQN LENDING AGENCV PRE-ALT FEE: ___. ,... .
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� IGERTIFVTHA7IHAVEREApTH1$APPLICATIONANDSTATETHATTHEABOVEINFQRMpf7ONi5GOPRECT. TUTAI�FEES �p '�� '
� IAGREE 70 COMPLY WITH ALL CITV AND CAUNTV ORDINANCES AN�STATE LAWS flELATING TO BUiIpING ��I_) ��� YJ i������
� CX�NSTRVGSKKi,RND Ft£RLDY AUT'-iORiZE REPPESENTATtYES OF THIS COUNTY T4 ENTER UPOM TME
ABOVE•MENTqNED FiiOPEFl1Y FOR INSPECTIpN PURPOSE9.
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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
PRESS
L'L,YI FIRMLY
JOBSITE
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CITY Iryi ng_ZIP ri2(c i Z.TEL.D .
APPLICANT Soat,"'e TEL. r�IIYta�
CONTRACTOR 1 14,1 1-6 Ir'P-CO Ce
ADDRESS'v el
CITY I n/irtP ZIP gzI,ice,TEL."4t-1 �I J L(
ARCH/ENG/
DESIGNER
ADDRESS/St'L n .
CITY,_r: s ZIP �2-L�r-TEL.'lk
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 REOUIRESA 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 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
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
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ L 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. 70", 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 SOUL 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-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS ROTH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I 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
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOR AND EFFECT.
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LICENSE CLASS LIC. N0.
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DATE/-CONTRACTOR PLA!'7T.-JT(V J[�
WORKERS'COMPENSATION DECLARATION
I HEREBY 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 SECTION 37000F THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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
FjE'.
PENSATK>NINSURANCE CARRIER AND POLICY NUMBER A/
ISSUED. MY KERS'C
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CARRIER � �C Y._M 0 N/ 1°_�ItS-(J-
POLICY NUMBER
iTHISSECTION NEEDNOT BE COMPLElYDOFTHE PERMIT IS FCRONE FR DREDDOIJARS($100)ORLESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 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 T PROVISIONS,
f0
DATE: I "C H'-0 I APPLICANT
I..J}pL•'t' '
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 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
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
L L(P)'I I'1', [tj re
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.
PERMITTEE NAME(PRINT)
2
7 SIGNATURE OF PERMITTEE DATE
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DATE APPLICATION NPERMIT
P
UMBER #1C ni J �I �J
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBAC KS
FRONT RW^
REAR ^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM 'r
Garage/Carport L t J
W Patio/Deck
UL- Pool/Spa
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Z Re-Root
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Valuation L ADJ.AREA
QUANTITY DESCRIPTION FEE
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ISSUANCE
SMIP
ENERGY P/C �'to Q o
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
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TOTAL FEES FFt
COMMENTS
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
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