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�� CITY OF DIAMOND BAB ��Y�G�
DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
,� 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 � PRESS
'��'� BUILDING PERMTT APPLICATION FIRMLY
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STATFMENT THAT NE OR GHE IS IICENSW PURSUANT TO 7HE PROVISIONS OF THE CONTMCTORS LI�
� CENSE UW(CHAPTER B((:OMMENCINO WITH SECTION 7W0)OF DIVISION 3 OF THE BUSINESSAND PRO� LL' PooUSpa
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� LICENSED CONTRACTORS OECLARATION -�
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I HEREBY AFFIRM UNDER F'ENALTY OF PEiWURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER �
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�X LIY UCENSE IS IN FULI FOHCE AND EFFECT. m
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� b' t HNVE M!D WILL MAINTAIN A CERTIFICATE OF CONSENT TC SE�F-INSUqE FOR WORKEAS' _ -
� COMPENSATION,�S PRONDED 9V SECTION 3]00 OF THE LABOR CODE,FOR THE PEPFORAIANCE W
Q / F THE WORK FOiI WHlCH TNIS PERMIT IS ISSUER �
QW / __I HAVE AND W!LL.MAi1JTAIN WORK[RS'GOMPENSATION INSURANGE,AS RE171/1NED 9Y SECTION
3�OOOF THE LA60F CUOE,i'OR TH[PERFORMANCE OFTH�WORK FOR WHICH TH1S PERMIT IS
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OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBY�FFIRM UN�ER PENALTY OF PERJURV TNAT THERE IS A COI�STRUCTION lEN'JING AGCNCV
FOR TNE FERFORMANCE OF THE WOFK FOR W H TH S PERMIT IS I SUED�5[C.3091,CIY.C.). -�
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W I AGREE TO COMPLV WITN ALL CITY AND COUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING
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~ WHITE—Department Copy,YELLOW—Finance Copy,PWK—Assesso�Copy,GOLDENRO�File Copy,GREEN—AppliranPs Copy
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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
JOBSITE
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ADDRESS
�Ny�� Ifl�j ��
APN LOT TRACT 5 2747
OWNER/7Z!!-
ADDRESS L 3'
CITY ZI TEL.-
APPLICANT TEL.
CONTRACTOR_v 77,-h�tg-e5r IF
ADDRESS 4119 1,W
CITY'ZI d TEL.
ARCH/ENG/
4
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DESIGNER
ADDRESS L-
CITY � di 9'ZIPS 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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
D 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,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).
D I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING 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.).
D 1 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 THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS
LIC. N0.
DATE CONTRACTOR-;
WORKERS
COMPENSATION DECLARATION
II HY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
A'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 FOFI WHICH THIS PERMIT IS ISSUED.
4
/
/_-I,AVE 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. MYWO KERS'COMPPENSSATION INSURAN E CARS/8..��NDD POLICY N BER ARF.:
CARRIER 4 Iii s�y,�,
POLICY NUMBER
(LHIS SECTlON NEB- NOT EE COMPETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS)_
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SIIALL NOT EMPLCY 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 TH .E PROV
ISIONS._
VI
.,�CJ'
DATE: 2-2 2'I APPLICANT. �0
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 ATTORNEYS 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 THE PERMIT IIS I SUED(SEC. 3097,CIV.C.).
LENDERS NAME L""4
LENDER'S ADDRESS
: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)
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SIGNATURE 0 P ITTEE DATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
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PRESS
FIRMLY
APPLICATION,'\
PERMIT I (0'AU�P/C
JJ
DATE NUMBER kJ #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR EI
SIDE/SIDE STREET RW ^
SIDE
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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PLUMBING
MECHANICAL
INSPECTlON FEE_
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES L.,
COMMENTS
RECPT. N0. LnAI PAID BY VALIDATION