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CITY OF DIAMOND BAR �I /�
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DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� 1��>J r y r'� � �'j
21660 E.Copley Drive Suite 190 PRESS /
��'%+����W BUII.DING PERMIT APPLICATION FIRMLY
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WTURE,VRIOR TO 1T9 ISSUNNCE,AL50 REW IRES iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
� STATEMENT THAT HE OR 5HE IS LICENSED PURSUAN7 70 THE PROVISIONS oF THE fANTMCTORs ll- � pool/S a
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� A CIVIL PENALTV OF NOT MORE THAN FNE HUNOFED DOLURS(f500).j:
^ ❑I,ASOWNEROFTHCPROPERrV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CoR1RI8fCl81
� WILL DO TME WORIC,AN�'fHE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR SPLE(SEC.]a4,BUSI� J
� NESS M!O PROFESSIONS��DE:THE CONTRAGTOR3 LICENSE LAW DOES NOT APPLV TO AN OWNER Of �
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� LICENSED CONTRACTORS DECLARATION J
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IHEREBYAFFIRMUNOERPENAITYOFPERIURYTNATIAMLICENSEDUNDERVROViSION50FCHAPTER �
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� �HAVEMIOWILLINAINTAW�CEfi71FICATEOFCAN5ENT70SELF-INSUREFORNlORKERS' 2
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0 ISSUED.MV WOR S'CAMRENSATION INSURAN CARRI R AN�POLICV NUMBE : CONSTRUGTION
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(} SHALLNOTEMPI.OYANYPERSONINIWVMANNERSOASTOBECOMESUBJECTTOTHE INSPECTIONFEE
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� SU&IECTTOTHE.WORKERS'COMFENSATIONVROVISIONSOFSECTION3]OOOFTHELABOR ISSUANCE � f . �`�.�v
� CADE,I SHALL FORTHWITH COMPLV WITH TMOSE PROVISIONS. __.
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DOLUflS�SI0�.000).IN ADDITION TG THE GOST Of COMPENSATION,DAMAGES AS PROYIDED FOR IN
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� I HEREBY 11FFlRM UNOER PENFITY OF PERJURY THAT THERE IS A CONSTRUCTION LENDMG AGENCV
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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
JOBSITE��j�//v Ifd'�r7'� '�f/-/' �/�--
ADDRESS(1 (- �"Y�,�/rj�li�/
APN LOT TRAC�S Z2-Gr'7
OWNER r't-
ADDRESS�&=C� �?��-STf-7
CITY���_ZIp��=TEL9�� �g>
APPLICANT TEL.
CONTRACTOR_��,��
ADDRESS
CITY ZIP TEL.
ARCH/ENG/r
DESIGNER�7�� '
ADDRESS 1.S/
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CITY�ZIP��TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLIWING REASON (SEC. 7037.5 BUSINESS AND PROFESSKNS CODE:ANV CITYOR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUG
TUBE, PRIOR 70 ITS ISSUIWCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS DCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER Y((XIMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSgNS CODE)OR THAT HE OR SHE IS EXEMP77HEREFROM AND THE BASIS FOR THEALLEGED E%EMP-
TION.ANV VIOLATgN OF SF_CTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).):
^ 1.AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7ola, BUSI-
NESS AND PROFESBKNJ.S tbDE:THE CONTRACTORS LICENSE LAW DOES N07 APPLY TO AN OWNER OF
PROPERTY WHO BUkDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PFK)VIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER�UILDER 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 PRO.IECT(SEC. 7041,BUSINESS ANU PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE IAW DOES NOT AP SLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
NATO CONTRACTS FOR SUI:H PROJECTS WITH ACONTRACTOR(S)LIOENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW.).
^ I AM EXEMPT UNDER SEC. B.f P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTKNI 7000)OF DIVISKNJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
EFFECT.
MY IgENSE IS IN FULL FORCE A
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UCENSE CLASS//LIC. N0. <,
DATE CIXJTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
VE AND WILL IAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 37000E 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
37000E THE LABUR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
RI RAND POLICY NUMBE
R
ISSUED. MY WOR S'COMRENSATION INSURAN�CA
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CARRIER�����G �E'! 'W
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POLICY NUMBER�4��� � �
(i}gSSECTlON NEED N07 BE OJbPLEfFD OF THE PERMIT IS FOR ONE MNi1FIED DOLLARS(8100)OR LESS).
I CERTIFY THAT IIJ THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN qNY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATKN! PROVISIONS OF SECTlON 3700 OF THE LABOR
HWITH COMPLY WITH THOSE PROVISIONS.
CODE,I SHALL FOR
T
DATE: �_/� „_�-' 'APPLICANT: V��4-,�---
WARNING: FAILURE TU SECURE WORKERS'COMPENSATION COVERAGE 15 UNUWFUL,AND SHALL BE
SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
OOLIARS (f 100,000),W ADDITK)N TG THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HERESY AFFIRM UNDER PENALTY Of PERJURY THAT TNERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OFT WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV C.).
I/Y/����
�///^'
LENDER'S NAME
_Y,
LENDER'S ADDRESS
�I CERTIFY THAT I HAVE READ THIS APPLICATKNJ AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY Wn'H ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
�CONSTRUCTlON,AND HEREBY AUTHORIZE REP ESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTKKJED PROPERTY FOR INSPECT NPURPOSES.
1 ��
II
1
I PERMITT E NAME(PRINT)
/li 6t.•��' �fi
T SIG OF PERMITf DA E
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy