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CI'TY OF DIAMOND BAR � ( �'�
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(909)860-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
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� WORKERS'COMVENSATI�N LAWS OF CA!JFCRNI4,ANC pGREE THAT IF I SHOVID tlECOME INSPECTION FEE _,. �
SUOJECT TOTHE WORKERS'COMPENSATION PR�VISIONS OF SECTION 37000F THE LABOR }��
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� IqGREETOCAMPLVWIfHALLCITVANDCOUNTVOR0INAVCESANDSTFTEIAWSRELATINGT06UILUING `/
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CITY OF DIAMOND BAR 4"�'-x f
DEPARTMENT OF COMMUNITY R DEVELOPMENT SE
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
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ADDRESS'�L�� �,�MLeY��S7E Z/�
APN LOT TRACT
OWNER�1�AI�MMs,�i1C S7UDIAp
ADDRESS 1?S2)�I_�}.I AV2
CITY ZIP gnz�2.TEL.
APPLICANT(Sit�,y��IM l�i 151c TEL�0.2$rn9.�d9"!.3
CONTRACTOR_
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
ZIP TEL
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CITY
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031 5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUO
TURE,PRIOR TO ITS ISSUAIJCE,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 IAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT FIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSK
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 W ITHIN ONE YEAR OF COMPLE-
TKNJ,THE OWNER-BUILDEFI WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPO'.�E OF SALE).
^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 APROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITN A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
U T AM EXEMPT UNDER SEC. B. 8 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 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
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LICENSE CLASS� LIC. N0. �w-+G
DATE� � :ZJG�3 CONTRACTORr.R'/S�-III C'1�-I�'�
lAIORKERS'COMPENSATION DECLARATION
BY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HER
E
I HAVE AND WILL AAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUEp.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORI(ERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED OF THE PEPMIT LS FOR ONE HUNDRED COLLARS(5100)OR LESS)
I CERTIFY THAT IIJ 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,ANp AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR
CODE, 1 SHALL ORTHWITH COMPLY WITH THOSE PROVISIONS.
� L C��APPLICANT: ,�- �-�il
1 DATE:
I
I I 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 IS100,000),IN PDDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTION 37080E THE LNBOP CODE. INTEREST,AND ATTORNEY'S FEES.
t CONSTRUCTION LENDING AGENCY
i
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANGI= OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097,CIV.C.).
LENDER'S NAME
- LENDER'S ADDRESS
I CERTIFY THAT I HAVE FIEAp THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORpINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PRI]PERN FOR INSPECTION PURPOSES.
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PERMITTEE NAME(PRINT)
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