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���_ CITY OF DIAMOND BAR �
DEPAItTMENT t3F COMMUNITY 8c DEVELOPMENT SERVICES
21660 E.Capley Drive Suitc 19Q �, l �l`J��C� -3� � �RESS
'%»*��W BUII.DING PERMTT APPLICATION FIRM�Y
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ADDRESS �
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� CONTRACTOR SIDE ❑
� ADDRESS �*�' -f
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� DESIGNER f U�.�� ,�—1�1•��f�f1t1' NO.DWEL NO. Np.
�' ADDRESS �' �_/.�[e.�"!'�.t��,�'C�--���- UNlTS_ STORIES BEDROOMS
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a �'?�� OWNER-BUILDER DECtARATiQN �L I F�' SFWADDIREM �' ����l ���
0 I HEREBY AFFIRM UNDEP CENALTV bF PER.ttIRY THAT 1 AM EXEMP7 FR�M THE CONTMCFOR5 U� �jal8g87C8/pOR i'� � � ' l
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.,� STATEMEN7 THAT NE OR 8HE IS LIGENSEG PUfiSUANT TO hIE PftOVISIONS C1F TNE CCINTPACTORS 11- {j� pooVS a
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fESSKYDS GODE)ORTNAT ME OR SHE IS EXEMPT TNEREfROM Ah0 TNf BA9i5 FOR THE ALLEGED EXEMP•
TqN.ANYVKHATpN4F5ECTIdN7Q11.68YANYAPPUCANTFORAPERMITSUBJECTSFHEAP?I.ICANTTO T` $�g-Fippf
� A CML PENALTY OF NOT MOqE THAN FIVE HUNDREQ DOLURS(l600).):
ry 01,�1SOYYNENOFTHEPPdPER7YOqMVEiAPLOVEESWITHWAOESASTHEIR50LECOMPEN5A710N, � GOrt1rt18lGldl
� W1L1.00 THE WiJPo4 AND THE STRUCTURE I5 NOT IN7E�D OR OFFERED FOR SAI.E{SEC.766i,BU51• _,3
NESS ANO PAOFESSIOIJS COQE:THE CONTMGTpRS LIGENSE UW CJOES NOT APPLY TQ AN OWNEHdF ,� "� ✓ C. '
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(� ftIpOLKLi iifS OR H6R OWN fMPIOVEES,PROVIDED TMAT SVpi IMPR6VEMENTS ARE NO7INTENDED OR m
W� OFFEREOWRSAIEiF.t10WEVER�E8U4LOMIGORIMPROYEMEMISSqDWiTNiN�7EYEAROFWAiPLE-
� TION,THE OWNEREUIIDER WILL HAVE THE BURpEN OF PROYING THAT HE t!A 5HE DID N4T BUIID OR
� iMPROVE WRT}IE PURPOSEOF SA4.E�.
W �i,A50iVNEiiOFTHEPROPERiV,AAiE%ClUSIVELYC6FiTqACiiNGW�THLICEN9EtlCANTRAGTORS
TO f70N5SftUGT THE PRWECT{^�C.7tlt4.8475MES5AND PROFESSIONS CODE:THE GfNli'RACTpR5 LF V$IU8f1011 . �' "�.� ADJ.AREA
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� i NEREBY AFFIRM UNOER PENALT'OF PERJUpv THAT I AM LICENSEO UN�EH PHOVISIONS Of CHAPTER Ve
(j, p�COMAtENC#1G iNli'H SEC7YJN l000j Oi OIViSiON 30�TNE eUSiNESS aN�PROFESSIONS CODE.AND Z ) \ \
MY IICEN5E IS IN FtlLL FORCE ANO EF Ct. m �y�{„� �4; j. �.,,3� �
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WORKERS'COMPENSATION DECIARAl"ION Q
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� 1 HERE9�AFFIRM UNDER PENPLTY OF PERJUHY(?NEOF'HE FOLLOWING DECIARATIt)NS; �t r �
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Q Fh1E WORK FOR WNlCN i M5 PE�7MIT f91SSVE0. � I
W t �HAVE M!O WILL MAiN7AIN WORKEflS'COMVENSATION INSUpANCE,AS REOUIREO 0Y SEC710N ��/p}� A�
� 3�a00i TME LABOH CODE.FOR TNE flERfORMANCE PF THE WORK FOR WHICH TH�4 PERMIT IS �[y 1'\t( � _A__���,ar��n"j�')�
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�} SHALI.NOT EMpLOY ANY VERSON M eVlY MANN:R SOAS TQ BECOME 5U&!EC!T4 TkE INSPECTION FEE _ �
Vy WtlRKERS'COMNENSATION I.AwS OF CALIFOHNIA N�'D AGFEE TMAT IF I SHOULD BECOME —��—�-� ' )
SUBJFCTTO THE WORKERS'C6MPEN5ATION PPOYi.�.iC1N5 OF SECTION 37000F THE IABOR �$SUANCE . 4 �/
� CODE.�SHALL fOR'*IiWiTH GOtdP�Y W!TM�H��PROVt570NS/ /
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d qA7E: /'�La"4/,APPUCANT: - ea�1 ' � �
w ENER�Y PIC �*,y�Sa� �
J WARNiNG.FAILURE t'O SECURE wOAKERS'CGMPENSaTiON C4v[RAGE i5 UNIAIVFUL ANO SFiAIL BE `—" �����
W SUBJECTANEMPLOYEFlTpCftlMINALPENAlTiESANQGiNtFINESUPTOQNEHUNOREDT}KXJSAND ENERGYPERMIT _... /�
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J SECTION�7o80F THE LABOF GOpE,INTEREST,AN�ATT4RNEV'S PEES. RETENTION FEE: .._..._... '>�, -�"} l � �
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� CONSTRUCT40N LENDING AGENCY PRE-ALT FEE . . .._ .
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� I HEREHYAFFIRM UNOER PENALTY OF PERJURV TMAT TNERE�5 A GONSTRUCTIpN LENDMG AGENCY _--
FOR TH€GERFOPMANCE OK7NE WORK PoR WF�Ai THIS PEFMR IS ISSUE �SEC.3097.CIV.C.i. �p � � �'
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� �CERTIFVTHATINAVEpEADTHISAPPLICATIONANDBTATETMATTHEA8CIVEINFORMATIONISCARRECT TUTALFEES �'}�� ���•���
W I AGREE TO cAi.iPLY W7TN ALL CITY AND CAt1NTY ORDINANCES ANU STATE LAWS REUTING TO 9UILDMG �
� CCMSTAUCTKMI,ANQNEAEBYAUTFNJRlTEREPRE9ENTA'�YESOF7HISGWNTYX}ENTEflUP6NTNE
� ABOVE•MENTIONEDRPpPERTYFOHINSPEC:�710NFURPOSES. COMMENTS .
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DIAMO%I)BAH,I
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190 C CS 3A t<
(909)860-3195 Fax(909)861-3117 7
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS G �I�C�C/�/�/Q-yZ�i�
ADDRESS t7 V-��/T
APN LOT TRACT-
OWNER pk
ADDRESS Ikell-f G
CITY ZI Z TEL. "7
APPLICANT TEL.
CONTRACTOR
ADDRESS-v i
CITY ZIP TEL.
ARCFVENG/
DESIGNER
ADDRESS
CITY ZI TELC
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 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 CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^t,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 SOD 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).
^ N,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 EF CT.
LICENSE CLASS LIC. N0.
DATE C'
'tcr7 9-4'J 101 CONTRACTOR
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'
COMPENSATKON,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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. MY WO RS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER
CARRIER/A o .
POLICY NUMBER T �! r
CTION?NEED'
FD NOT BE COMPLETED OF TH
FERMI'IS FO
E HUNDRED DOLLARS
0
L
E
R
N
($100)OR
ESS).
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 THIE PROVISIONS
r
DATE:
J V APPLICANT.
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 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
(SEC. 3087,CIV.C.).
FOR THE PERFORMANCE OF THE WORK FOR W THIS PERMIT IS ISSU
P
E
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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 INSPE ION PURPOSES.
PERMITTEE NAME(PRINT)
'�77
SIGNATU F PERMITTEE-D E
PERMIT
APPL
MI
ICATION /C
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UMBER
DATE 1 ""'
#
ISSUE
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COST. GROUP
ZONING SETBACKS
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SIDE/SIDE STREET RW^
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PROPOSED USE
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UNITS STORIES BEDROOMS
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LwLI Patio/Deck
LL Pool/Spa
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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PRE-ALT FEE:
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TOTAL FEES I�
COMMENTS
RECPT. N0. PAID BY I 4U VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy