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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES C%
IILrp : 21810 Copley Drive, Diamond liar, CA 91765 V F'RESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION FIRMLY
JOB SITE ADDRESS
APN LOT TRACT
OWNER A4i=Snh1
ADDRESS (�t�LSO
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR S C C'� Cc C.
ADDRESt I �j
CITY ZIP O TEL. 3)L �Zz�2�% /b
ARCH/ENG/DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reason(s)
indicated below by the checkmark(s), I have placed next to the applicable item(s) [Section 7031.5, Business and
Professions Code: Any city or county that requires a permit to construct alter, improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division 3 of the Business and Professions Code] or that he or she is exempt from licensure and the basis for
the alleged exemption. 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).
U 1, as owner of the property, or my employees with wages as their sole compensation, will do U all of or U portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or improves the property, provided that the improvements are not intended or offered for sale. If however, the building or
improvement is sold within one year of completion, the Owner -Builder will have the burden of proving that it was not built
or improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors'State
License Law.).
(� I am exempt from licensure under the Contractor's State License law for the following reason(s):
By my signature below I acknowledge that, except for my personal residence in which 1 must have resided for at least one
year prior to completion of the improvements covered by this pannit,l cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code is available upon request when this application is submitted or at
the following Web site: http/www.leginfo.ca.gov/calaw.html.
DATE: SIGN:
LICENSED CONTRACTOR'S 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 forcceefand effect.
LICENSE CLASS: LIC. NO.: 11 Ql
DATE: CONTRACTOR: ee � Gc—k
WORKER'S COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance of the workfor which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE 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 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 Worker's
Compensation rove ns of Section 3700 of the LV[ e, I shall forthwith com with those provisions.
DATEY�APPLICANT: X
WARNING: Fai re, to secure Worker's Compensation Wage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, interest, and attorney's tees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work for
which this permit is issued (Sec. 3097, Civ. C.).
LENDER'S NAME
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 the ve-mentim7d, property fj inspection purposes.
PERMI NAM RINT)
2 3
IGNATUR OF P EE DATE
APPLICATION DATE: Ia ( lli?5 P/C# -
ISSUE DATE: b1 ( PERMIT# f 3 —39*_�
TYPE CONST. OCC GROUP:
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
# DWEL. UNITS If STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
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Patio/Deck
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Pool/Spa
0
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Re -Roof
0
Commercial
m
Valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC: 5-7 • b(o
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BSAF:
TOTAL FEES
COMMENTS:
RECEIPT tt MCN PAID BY: S VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy, GOLDENROD — File Copy, GREEN — Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS:
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