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CITY OF DIAMOI�iI}BAR ����
-�`��""'— DEPARTMENT OF COMMUNITY&DEVELOPMENT S�RVICES
2166�0 E.Copley Ikive Suite 19Ci
(909)86d-3195 Fa�c{904}861-3117 PRESS
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FOH THE PEHfORMANGE OF THE WORK FOR W H THIS FEFMI7IS ISSUEO{SEC.]057,CIV.Q). i �'7"�T"—
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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
�'——
3
ADDRESS
APN LOT TRACT
OWNER Pi.,t---f/YIf_S
ADDRESS-)3
CITY D.sawAu)A ziPql_li 7L E Q
APPLICANT TEL,
CONTRACTOR P&I-/F f-f iyt
ADDRESS 19461 L?JNJ I�i4�(1 STf
CITY T_.Q yin/L ZIP e41z1 TEL.'349 797-
ARCH/ENG/41 '/00
DESIGNER
ADDRESS
CITY JAL. �S-ZIP TEL.
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 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 CAVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
DI,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 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
Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THY BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0,/7'5_13
DATE 9-CONTRACTOR a IL
a?
�-kP-ci
WORKERS'COMPENSATION DECLARATION
I HEREB'AFFIRM UNDER PENALTY OF PER JURY ONE OF THE FOLLOWING DECLARATIONS:
AVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODEE FOR THE PERFORMANCE
F 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
ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
Em Pc-t
S
IFI �
PC
CARRIER I
�
POLICY NUYBER i.y C7 RL 3�/I f}
(THIS SECTION NEED NOT BE COMPLETED OF THE PERIAT IS FOR ONE HUNDRED DOLLARS($100)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 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
AD. FORTHWITH COMPLY WITH THOSE PROVISIONS.
CODE,ISH
HA'
DATE:_120-jW APPLICANT:_(.N LTE
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 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR W H THIS PERMIT IS ISSUED(SEC. 3097,CIV C).
LENDERS NAME�����
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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)•'�••//
D SIGN RE OF PERMITT DATE
APPLICATION NPERMIT UMBER IC� #P
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DATE 0
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
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SIDE/SIDE STREET RW^
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PROPOSED USE
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UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM (
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W Patio/Deck
LL Pool/Spa
Z Re-Roof
0 Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
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ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES�JI I rJ
COMMENTS
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy