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CITY�F DIAMOND BAEC
- - - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21b60 E.Copley Urive Suite 19Q
(9Q4)8bd-3143 Farc(909}861-3117 PRESS
'�»�f BUILDING PERMIT APPLICATION FIRMLY
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a ADDRESS � � + � ti/ ...— DATE�, � �� " NUMBER� #�.I—!�
$ ISSUE � TYPE OCC
APN LOT TRACT '� DATE �� CONST. GROUP
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ADDRESS UNiTS STORiES BEC7R{?OMS
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rn DESCRIPTICIN SQ.FT. FACTOR PSF ADJ.AREANALUATION
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CENSS UW FOR TFiE iOLLOWMti REASON(SEC.70.11.5 BUSMiE55ANQ PPOFESS�ONu^CODE:ANY CiTYOR {j)
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STATEMENT THAT HE OR SHE IS LICENSE�pURSUANT Tp THE PROVISIONS OF TME GON7flAC70RS LI•
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VALL bb THE WOqK,AND 7HE STRUCTUftE I6 NOT INTENDED OR OFFERED FOR SALE(SEC.�014,BUSI. J
tiESS MKl PROFESSIONS iX}DE:THE CONTMCTORS llCENSE 6AW DOES NOT APPIY TO AN OWNER OF �
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3JW OF TH£1A90R COOE,FOR THE PEf1FOP.IAA?iCE O�TtiE WORK FOR WNICH THtS PERMiT IS _,_______iL°��LlG�
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C,�J SHALLNOt EMPt_QY ANY FENSON IN F.R So AS Ta BECOME SU9JECT 70TH€ _ _
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DOI.LARS(�100,pq0),IN 1���ITION T07HE GOST OF COMPENSAT'�ON,OAMAGES AS CflOViDED FOR IN �F�^--�--_�y--- -
� SECTION3'1o80pTHEL,4BORCODE,INTEREST.ANOMTORNEY'SFEE'S. f��TENTIONFEE: � '� _
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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d I AGREE TO CAMPLV WITH AI.L CITV AND COUNTY ORDINPNCES MNO STATE LAws RELATING TO BUILDING �
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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
0
JOBSITE 10
Q
I
ADDRESS �/
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR V4Y1 G
ADDRESS
CITY ZIP TE
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 REOUIRESA 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 CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS)5500).):
^ 1,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 OFI 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 YEAROF 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).
^ L AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER 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 C ES LTC. N0.J
h
DATE CONTRACTO
Ir--
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 SECTION 3700 OF 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
INSUR E CARRIE ND POLICY NUMBER ARE:
ISSUED. MV WORKERS'PENSA
CARRIER
POLICY NUMBER- !v to Q C2-C?
(MLS SECTION NETf)NOT BE COMPU=TED OFTFE PERMIT IS FOR ONE IiIMDRED DOI LIRS($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 ER 50 AS TO BECOME SUBJECT TO THE
LAWS OF IFOR IA.AND AGREE THAT I SHOULD BECOME
WORKERS'COMPENSATION OM
SUBJECT TO THE.WORKERS'COMPEN TION P OVISIONS OF SECT N 700 OF THE LABOR
D I SH ORTNWITH COMPLY WITH T E-VISIONS
DATE:APPLICANT:
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($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 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 THE 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.
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.
NAME PRINT)
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2,!1,ON
DATE
.SIGNM90FPERW-TE
APPLICATION n f�PERMIT"LV)P/C-I (p 0
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DATE NUMBER
# �V
ISSUE
�TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE 126 in U
!I C&Y-177
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL Pool/Spa
0
Z Re-Roof
Commercial
5
co
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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U
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0
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MECHANICAL
INSPECTlON FEE---
ISSUANCEt
APR
SMIP
ENERGY P/C
ENERGY PERMIT B i
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 0
COMMENTS
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RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREENU-Applicant's Copy
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