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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
ADDRESS mG
APN LOT TRACT
OWNER CC' %Z —^
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CITY w _"Z ZIP 0 7I TEC
APPLICANT,qr.ZoWAt2tt/t5
CONTRACTOR C-%/ ®N
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CITY ZU 4r/+//i- ZIP _ 6 2-)4_ TELC _/
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DESIGNER
ADDRESS
CITY _ ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LH
CENSE LAW FOR THE FOLLOWING REASON (SEC. 703/.5 BUSINESS AND PROFESSIONS CODE: ANY CITV OR
COUNTY WHICH REMIRESA PERMITTO CONSTRUCT, ALTER IMPROVE, DEMOLISH. OR REPAIRANYSTRUC-
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 U,
CENSE LAW (CHAPTER u (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 VKAATION OF SECTION 7031.5 BYANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANTTO
A CMLPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
C31, AS OWN ER OF THE PROPERTY, OR MY EMPLOYEES WITH WAG ES 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 OCMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
111, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70", BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTO THE OONTRAC-
TORSUCENSELAw.).
❑ IAM EXEMPT UNDER SEC. S. 5 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
0 (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. NO.
DATE l rL,4 — CONTRACTOR /J
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS'.
_1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37GOOFTHE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,
Z,
HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOUIFED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFO RMANCE OF THE WORK FOR WHICH THIS PE RMIT IS
ISSUED. MY WORKERS,
COMPENSATION INSURANCE CA®81GFi AND POLICY NUMBER ARE:
CARRIER / ��
POLICY NUMBER n Z.
(TI is sECr10N! WEDNOT BE COMPLETIDCFTHE PERMIT IS RM CNE HUNDRED DOLLARS (5100) 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 1 SHOULD BECOME
SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTIO N3 OF THE LABOR
CODE, I S ALL FORTHWITH COMPLY WITH THOSE PRP VISIONS. r
DATE: APPLICANT G
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 (51 00,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
i
I OR THE EFIRM UNDER PENALTY OF PERJURY THAT IS PE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED (SED 303r, CIV Cl.
I
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
fCONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTION ED PROPERTY FOR INSPECT'�POSES. �1
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PERMITTEE NAME (P
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SIGNATUnEOFPERAgE DATE
PRESS
FIRMLY
APPLICATION�j /, r,Av PERMIT P/C
DATE .✓/ t(` NUMBER #
ISSUE /f TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW C
REAR C
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
WPatio/Deck
U-
PooI/SPa
ZRe
-Roof
Commercial -
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MID MECHANICAL _� P1
INSPECTION FEE
ISSUANCE
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ENERGY PIC Cy K -D BAR
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ENERGY PERMIT
AND ^1
RETENTION FEE: i
PRE -ALT FEE:
TOTAL FEES
COMMENTS
RECPT NO. PAID BY VALIDATION
WHITE --Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOWENROt)— Ile GOPy, GHhEN—Applloant'S L OPy
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