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DEPART?�IENT OF COMMUNITY&DEVELOPMENT SERVICES
� 21660 E.Copley Drive Suite 190 PRESS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)851-3117
BUILDING PERMIT APPLICATION
ADDRESS(t1Qq [�OSI k LL-A-bV
APN LOT TRACT
OWNER M1 r C'z n
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR S�•R.S 1°P'('a- P
ADDRESS io4 L-U .U1 0- 1
CITY L 4-S ZIP90(i71)TEL.F-S00 9-
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 REQUIRES A 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($500).):
^ 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 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 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).
^ 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDIOR 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
B(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. N0. 77'll �f, 1 ' �
DATE 3- 1--G G CONTRACTOR-vs--Q-S �'<y
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWIN
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEL
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE LABOR
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS P
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECT
CARRIER 140 'V t J� �'
+
Lu0*1_4C1Gt11//,/-
POLICY NUMBER iD
SU&lE�CTTOITHE: WORKERS'COMPENSAT OVISION OF CTlON
RETHTI
WORKERS'COMPENSATION LAWS OF CALI IA,AND RE THAT IF
SHALL NOT EMPLOY ANY PERSON ANY R SO
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS
(THIS SECTION NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE I-LFDR
CODE.SHA44 FORTHWITH COMPLY WITH
WARNING: FAILURE TO SECURE WORKERS'COMPS ION COVEV.AGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN IVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(3100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LIBOR CODE,INTEREST,AND ATTORNEYS 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 WI1'H 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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PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE
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PRESS
FIRMLY
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APPLICATION PERMIT
6/0
1 NUMBER #
DATE
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
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PROPOSED USES C-3-1 � �b-y 9 G S(ZCS
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UNITS STORIES BEDROOMS
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SFR/ADD/REM
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ISSUANCE MAR 16 2000-Gtr
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CITY OF DLAMONDBARR
ENERGY P/C
ENERGY PERMIT BI TH DING ANT)SAFETY
RETENTION FEE:
PRE-ALT FEE: -
TOTAL FEES I D f-V
COMMENTS
RECPT N0. PAID BY VALIDATION
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ssf r3ECORED