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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES
21825 E. ColDley Dave 1
(S09)8G0-3195 Fax(9Q9j 861-3117�1
BUILDING; PERMIT APPLICATION �t��j,�,v,�e��'
FIRMLY
JOBSITE�+�,��
ADDRESS 2155 C��C2��
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APN I.OT
TRA:;T
OWNER IC�/� �
ADDRESS(403�DI/�MOND BAR_�d_��
CITY QJAMOI�fb.E,�2 ZIP 9IT(�TEL.�pg-4Q4,6
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APPLICANT N�IG j{j�{(�---TEL_T_a_=��
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CONTRACTOR-
ADDRESS_
CITY ZIP TEL.
ARCH/ENG/
DESIGNER�"� «Fi �
ADDRESS 36ao n�1LSHfRE BI.V�
CITY_�Q�j�ZIP�1Q_TEL-�Fi-
OWNER-BUI;-DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY T HAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOLLOWING REASON (SEC. 7031.5 BU SINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESNPERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIRANY STRUC-
TURE,PRIOR TO ITS ISSUAVC E,ALSO REQUIRES THE APP! ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SIiE IS LICENSED PURSUANT TC THE PROVISIGNS OF THE CONTPACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WIT'I SECTION 7W0)OF DIVISION 3 OF THE BUSINESS AND PRO
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BAS%S FOR THE ALLEGED EXEMP-
TION.ANV VIOLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUdJEC FS I HE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HIINDRED DOLLARS(E�WI).
^ I,AS OWNER OF THE PROPE RN,OR MY EMPLOYEES WITH WAGES ASTREIR SOLE COMPENSATION.
WILL DO THE WORK,AND TiiE STRUCTURE IS N07 INT ENDED OR OFFERED FOR SALE(SEC. 7044,BUSK
NESS AND PROFESSIONS CODE:THE CONE RACTORS LICEhISE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO GOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IE HOW EVER,THE BUILDING OR IMPRO�JEMENT IS SOLD W(THIN ONE V EAH OF COM PLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DiD NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
1'I,AS OWNER OF THE PROPERTY,AM EXCL.USIVF_L�CGNTH gCTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. ]044, BUSINESS AND PF:OFESSIONS CODE-.THE CONTRACTORS I_I�
CENSE LAW DOES NOT APPI V TO AN OWNER OF A PROPERi'i WHO gLILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTOF(SI L ICENSEO PU �95UANT TO THE CONTRAC-
TORS LICENSE LAW.I.
�I I AM EXEMPT UNDER SEC.-� - - � 8.8 P.C. FOR THIS REASON
DATE OWNER- -- - - -
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJU RV THAT i AM LICENSED'UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTlON 7oW I OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS___LIC. N0.___.,
DATE_ CONTRACTOR-_,..-_-._-_
WCfIKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PE VALTY OF PEFJL'RV ONE OF TH F FOLLOWING DECLARATIONS.
I HAVE AND WILL MAINTAIN A CERTIFI^.ATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS°ROVIDED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR YIHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3]00 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED-MV WORKE EIS'COMPENSATION INSURANCE CARRIER AND POI�IGY NUMBER ARE'.
CARRIER
POLICYNUMBER_,_..__-_- ._ -
(THIS SECTKKJ NEED MJ T BE Ci7MPIETED OF THE PERMI'IS FOR ONE HUNDRED DOI_IARS(b100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO PECOME SUBJ F.CT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOIILD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PHCVIS IONS OF SECTION 3]00 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE°ROVIS IONS.
DATE APPLICANT:
WARNING: FAILURE TO SECURE WORKEP.S'COMPENSATION COVEFIAGE IS VNIAWFILL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENAI-TIES AND CIVIL FINES UP i0 ONE HUNDRED THGUSAND
DOLLARS(EIOO.OWI. IN ADDITION TO THE COST GF COMPENSATION. DAMAGES AS PROVIDED FOR�N
SECTION 3708 OF THE LABOR CODE,INTEREST.ANCI ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENf.Y
I HEREBY AFFIRM UNDER PEh:ALN OF PE-9JURV THAT THERE IS AGONS"� RIIGION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOP,WHICH THIS PERMIT IS ISSUED ISEC. 3097,CI V.C.j-
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVF HEAD-PHIS APPLICATION AND STATE THAT i HE ABOVE INFORMATION IS CGRREC7
I AGREE TO COMPLY WITH ALI CITY AND COUNTY OHDINAN CES AND S'.ATE LAMS RELATING TO BUILDING
CONSTRUCTION,AND HEREB'f AUTHORIZE REPRESENTATIVES OF THIS COVNN TO ENTER UPON'HE
ABOVE�M ENTION ED PROPE R'�Y FOR INSPECTION PURPOSES
PERMITTEE NAME;PRINT]
SIGNATURE OF PERMI r. IATF
WNITF--Oeoartrnent Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicanrs Copy
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