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�7,,``_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
„ � 2166Q E.Copley Ihive Suite 190
t��a�-si�s�a����e6i-ai i� PRESS
'�'^ BUII,DING PERMIT APPLICATION FIRMLY
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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 r
353
1 C'
ADDRESS
APN LOT T CT
OWNER
ADDRESS cjj!E2n&At-->
CITY ZIPJJZ��TELJ79,
APPLICANT T
CONTRACTOR
ADDRESS
CITY ZIP EL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY 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 B (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).):
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).
D I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCTTHE PROJIFCT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOTAPP..Y 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 I AM EXEMPT UNDER SEC. B 8 PC. FOR THIS REASON
DATE OWNEFI
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
B(COMMENCING WITH SECTlON 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE�.B(,JD
MY LICENSE IS IN FULL FORCE AND EFFECT. l,f�
LICENSE CLASS 6 fL LAC N0. -�/??
DATE_/CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
I HAV
AINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKER
COMP ENS AS PROVIDED BY SECTION 3100 OF THE LABOR CODE,FOR THE PERFORMANCE
T
OF ORK FOR WHICH THIS PERMIT IS ISSUED.
,1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR;ODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
(AANCE CARRIE AND POLICY NUM
ISSUED. MY WORKERS'CO
NSLI
TIION I
MPPENSSA
AT
IN
�I
CARRIER_(
POLICY NUMBER 9 .��
-fi r
(THIS SECTION NEED NOT BE C17M 1 FTED OF THE PEFAYT 15 FOR ONE HUNDRED DOLLARS(5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT!S ISSUED,I
SHALL NOT EMPLOY :ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMP NI,ATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO TH RKERS'COMPENSATI PRO'IS.-'NS OF SECTION 3700 OF THE LABOR
I
ONS.
CODE,H RT11yJITH COMPLY WI R
DATE
APPLICANT
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AN
SUBJECT AN EMPLOYER TO C RIMINAL 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 3700 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'HE 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.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTI L PURPOSES.
I I..�/v�
PERMITTEE NAME(P I
SIGNATURE OF PERM E AT
APPLICATION,(PERMIT P/C
R
DATENUMBE
#
ISSUE TYPE OCC
DATE_CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL Pool/Spa
0
Re-Root
Z
Commercial
I1
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
H
U
L
CI D
C ONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
GY P/C
ENERGY PERMIT C
TAY OF DIAMC)�B
��3T
REfENTION FEE: BVll .DgNr ANTI C AT+G�N
PRE-ALT FEE:
TOTAL FEES
COMMENTS!
RECPT N0./,- PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
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