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�� CITY OF DIAMOND BAI�L
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DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES --'��
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NRE.PRIOR iq 1T5 iSSUtNCE hi.50 REGt7!RES SNE APPLiCANT F6R SUCH PERfiitT TO FiLE A SIGNED
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� CR75EUW(CNAPTER9{�MENCM/flWiTfiSECTlON7aW}(1F�IVISlON30FTHEBUSINESSANDPRO- � P —
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� 9 S��NCINO WILN SfC710N'IoOo)OF D�ViSN]N a OF THE BUSINE55PND PROFESSIQNS COUE,ANU �
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� WOPKERS'COMPENSA?N?N LAWS OF CAL�FONNIA,AND AOREE THAT IF I SHOU4D BECOME , -
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�- FDA THE PfRFOflMANCE OF THE WORK FOR H THIS PEfiMIT IS IS5UE0(SEC.308),CIV C.�.
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� iAGRE.E FQ(:OMPiY WITH ALl CITY PND COUNTY ORDINANCESANO STATE LAWS RELATING f0 BUILDING
� CONSTRUCTfON.ANDMFREBYAUTHOR¢EREPRESENTATIVESOFTHISC011NTY70ENTEflUP6M[HE
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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
FIRMLY
JOBSITE
ADDRESS 23.7 G/9NV41,4I Y1.57�?cT
APN LOT 0'7 TRACT
OWNER_PULT r5rvrfS
ADDRESS NV'!
CITY J)J1gIH A/D/.00ZIP TE.
APPLICANT TEL.
CONTRACTOR A9dL-77 D
ADDRESS l0e/)1,4A/
CITY/lA/t ZIP}La[aTE.
c�
ARCWENG/
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DESIGNER Lloo.
ADDRESS
CITY/I!E-Lt lf(r�-ZIP UTEL
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 REQUIRESA PERMITTO 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 FORA 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,BU51.
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 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 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.).
^ 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 FORCE AND EFFECT.
rJ yr,
NO
LICENSE CLASS LIC
DAT D CONTRACTOR<L H-/Pte
WORKERS'COMPENSATION DECLARATION
HERE AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
W
�I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERSCOMPENSATION INSURANCE,AS REQUIRED BY SECTION
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:
C0 .
r-,c 1
o�o�
0
CARRIER
POLICY NUM R L.'G
Nr�r•S-0!
(THIS SECTION NEED NOT BECCMAR-ETED OFTHE PERMIT IS FOR ONE HUIGREDDOUARS($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 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,
n4
DATE:APPLICANT. PuLTA I�rn S
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 ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 15 A CONSTRUCTION LENDING AGENCY
SEC. 3097,CIV.C.).
THIS PERMIT IS
ISSUED(
FOR THE PERFORMANCE OF THE WORK FOR
H
00
SI
/^'
(S
LENDERS NAME J �-/_L(- il€T
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.
C
PERMITTE AME IP INTO
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SIGNA E F PERMITT DATE
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DATE CATION NPERMIT
APPLI P/C--
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ISSUE TYPE OCC
DATE CONST.GROUP
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FRONT RW^
REAR
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PROPOSED USE
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UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. E ACTOR P SF ADJ.AREANALUATION
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