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PRESS
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
JOBSITE
ADDRESS ..2 3 7 ---- e.A 1,1 V LtAi I."/3 Tir C. 7--
APN LOT 4-3 TRACT 5-dz.a e 7
OWNER Pk(/..--r-C I-tel rv?e,S
ADDRESS .-- .. - c-7—
CITY Di.gt-r,-,A,..O .A.4-,...zip X,,, TE a '. 'Oniti. i_S-
APPLICANT H1-lA/2.:VEL.
,/J/9...&V
CONTRACTOR Pa 1--7--f 1-4-0,1,7 f
ADDRESS /"" .... 14.—la R... ' e- A/
crry „91,--_„t/e_ ZIP 1.76 0-TEL
ARCH/ENG/5"7100
DESIGNER /4/5 ye- D.1/4-i\/
ADDRESS c)411)AIe'b...,l a e.-J" i'A/g. -L-) ..._•
CITY CI /VP z.,,,,f761,Pr: 9a6r40TEL Liq)?e,,,-.) .--
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OWNER-BUILDER DECLARATION 0 1 if....\-
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.0 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRES A PERINI-TO cONSTRUCT,ALTER,IMPROVE, DEMOUSH,OR REPNR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION MO)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 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CPAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).).
0 L AS OWNER OFfHE 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 VA-10 DOES SUCH WORK HIMSELF OR HERSELF OR
114ROUG04 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).
0 I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT TFIE 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 UCENSE LAW.).
0 I AM EXEMPT UNDER SEC. B&PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 7 AM LICENSED UNDER pROWSIONS 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.
LICENSE CLASS & Lio No. -3--/73-5 3
DATE 9-3 0-4,I CONTRACTOR PLI 1-71.- HOPPI I 5
Ey—P• e e ./...--P-.
WORKERS'COMPENSATION DECLARATION
I HERE AFRRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
ENSATION,AS pRoV^DED BY SECTlON 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I.
I
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR 03DE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIERPIqe-I_Eis—......e.iti_eztLe.,../A.6• (7.62,
? POLICY NUMBER if d 'el ie.l._ 4/.• //5:;i 7A
. e X-Fl ^ 5-7-4> 1
MIS SECTION NEBO N07 BE COMPLETED OFTHE PERMIT IS RDA ONE HUNDRED DOLLARS(5100)OR LMS).
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
WORI:ERS 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
)
I DATE:we/-6 PAPPLICANT: el//....7.-22.. Lieding,;$
3
i WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL IRE
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,
3
CONSTRUCTlON LENDING AGENCY
5
C I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
" FORME PERFORMANCE OF THE WORK F07WHICN THIS PERMIT IS ISSUED(SEC. 3097. CM CL .
5
LENDER'S NAME Ad1GIA.,1 t.-.. - "-r i--h0/7,7 reip_..p)
,C.
LENDER'S ADDRESS
F.
C I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
u
L I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING
, CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
et: ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
5
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5
D PEFIMITT NAME(PR
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RETENTION FEE: 1 'i oct .)),1
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RECPT N0._s_ j_PAID BY VIM
WHITE-Department Copy. YE stance Copy, -ssessor COPY. (AUWENI-IUU'FIIB LOPY, -Applicant's Copy
CITY OF DIAMOND BAR INS'ECT/ON RECORD
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ROUND PLUMBING UNDER FLOOR CONDUIT
AB GRADE FIREPLACE FOUNDATION
EMP POWER RREPLACE BOND BEAM
ATER SERVICE MID HT,BOND BEAM
DOF SHEATHING I:" 7-01 8 FT. BOND BEAM
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RAMINGNENT/LIATION I pc., , FINAL BOND BEAM
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OUGH ELECTRIC I
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.EWER FINAL ENG. _
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iEEP PIT/LL. . . . ON SITE IMPS.
AS AIR TEST FINAL ZONING ,
'INAL CONST. 1 AL FIRE DEPT. FINAL
INAL HEATING fijik2115ji _, , , HEALTH DEPT. FINAL
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'INAL ELECTRIC DEV. FEES PAID
'NAL PLUMBING -T 1—ENERGY
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