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_�� _ CIT'Y OF DIAMOND BAR
DEPAR'TI�NT OF COI�IlvIUN1TY 8c DEVELOPMENT SERVICES ,
,,,¢ 21825 E.Coplcy Drive
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BUILDING PERMIT APPLICATION FI RMLY
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1 HEREBV AFFIRAI UN�ER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTMCTOfiS ll- G8f898/C9tP01[
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STATEMENT 7HAT HE OR SME IS LICENSED PVRSUANT TO THE PROVISIONS OF hlE CONTRACTORS L6
O� CENSE lAW(CMAPTER 9(WMMENCINO WITH SECTION 7000)OF OIVIS�ON 3 OF THE BUSMESSAHD PRO- u' Pool/Spa
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z 1MLL DO h1E WORN,AN�THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SAlE(SEC.7W�,BU51- J
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1 HEREBV AFFIqM UNDER PF-NAI.TY OF PERJUqY THAT 1 MI UCENSED UNOER PROVISIONS OF CHAPTER �
p� Y(COMMENCNJG WITN SECTqN 7000)OF DIVISION 9 OF THE B1151NESS AND GROFESSION$COOE,ANO Z �
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�� CAMPENSATION.AS PRWIDED BY SECTION J7000F THE U60H CODE.FOR THE PERFORMANCE U
Q OF THE WORK PoH WHICM TNIS VEFMIT IS ISSUED. �
� __I HRYE AND WILL MAINTAiN WOqKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION �7
Q� 37000F THE LABOR CAOE.FOq THE PERFORMANCE OF 7HE WORK FOfl WHICH 7HIS PERMIT I$ I �I , ' ��
J ISSUED.MV N/ORKFRS'COMPENSATION INSU,w/�CE CPRRIER AND POLICY NUMBER ARE: CONSTRUCTION i�f/
j CARRIER� � �^ ' 'lG�— PLAN REVIEW
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(} SHAI.L NOT EIAPLCYANV PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
� WORKERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE
= SUBJEC7 TC THE YqRKERS'COMPENSATION PRO SIONS OF SEC710N 37000F THE LABOR ,
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� SU&IECTANEMPLOVERTOCRIAIINALPENALTIE DCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGVPERMIT
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J SECTqN3]oBOFTHELA60RCODE,MTEflEST,ANDATTOFNEV'SFEES. �
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRIA UNDER�ENALN OF PERJURY THAT THERE IS ACANSTRUCTION LENDING AGENCY
FOA THE PERf4FMANCE OF THE WORN FOR WHICH THIS PERAIIT IS ISSUED�SEC.3081,C1V.C.).
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� LENDEA'S NAME_
�— IENDER'S ADDNE55_ ///
w I CERTIFY TNAT I NAVE RFAD THIS A7PLICATIDN AND STATE THAT THE ABOVE INFOHMATION IS CORRECT. TOTAL FEES ��Vl-"��
� I ACREE TO CdAVLY W1TN ALl CilY AN�COUNTY OqDINANCES AND STATE UWS REUTING iO BUIL�WG / ! J
� CONSTRUCTION,AN�HEqEBV AUTHOqRE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE [J
Z FBOVE-MENTIONED VROCERTY FOR INSPECTION PURPOSES. COMMENTS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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PRESS
FIRMLY
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JOBSITE �
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ADDRESS-�
APN LOT TRACT
OWNER I
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APPLICANT TEL.
CONTRACTOR L a
ADORE S 7
CITY I ZIP Z Lj TEL.
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 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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
D I,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 COOE: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 OFCOMPLE-
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 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 ACONTRACTOR(S)LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
D I AM EXEMPT UNDEP,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 EFFECT.
LICENSE CLASS LIC. NO
DATE CONTRACTOR A I �'S r-01�
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'
COMPENSATION.AS PROVIDED BY SECTlON 37000F THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE 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
�NCE CARRIER AND POLICY NUMBER ARE:
WORKERS
'COMPENSATIONINSU
R
ISSUED. MY
��
J
CARRIER X11-jam' l�.cl
POLICY NUMBER
(THIS SECTION NEED NOT BECOMPLETFD OFTFE PERMIT IS FORONE 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
II SIONS OF SECTION 3700 OF THE LABOR
SUBJECT TO THE WORKERS'COMPENSATIO
e
CODE I SH FORTHWITH COMPLY WITH TOVISIONS.
DATE:/�PPLICANT:
WARNNG: AILURE TO SECURE WORKERS'COMP COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIE FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5700,000),IN ADDITION TO THE COST COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST.AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER-ENALTY 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
LENDERS 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 UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy