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a ` � CITY OF DIAMOIVD BAR I + \,+
- �� �- DEPARTMENT QF COMMUNITY&DEVELOPMENT SERVICES '
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, .���^�,�W BUILDING PERMTT APPLICATION ��'" �� FlRMLY
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(� i HEREBY AFFliOA INDER PEtiM.iY OF PEMiRY THAT I M1 EXEMPT FROA1 THE CONTRACTORS LI- G3f3!]eiCHfp01t {., ��' ^ �
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STATEMEMT lHR7 HE OR SHE iS IICENSED PUA3U0.NT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(Cf1APTER P{LUMMENqNG WITM SECTI�N 70Do)QF DIYISION 30f tHE BUSINESS AN6 PP6� � PooVSpa
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� t�SSAND VP�FESSI9N3 CPDE THE CONTRACTORS LICENSE LAW DOES NOT APPI.V t0 AN OWNER OF \
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U ISATE_ 7 3 O1 C4MRACTOR__ ("U1�_`G�' Homes i �.- - y� '
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� WORKERS'CdMPENSATION DECI.ARATlQN d �
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C_? HAVEM1DWIlLMAWTAINACERFIfICA7EOFCDN5ENT705E1F-INSUREfORWORKERS' _ ��]'�, { � '1`�
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, OF TNE WORK FOR WHICNTHIS PERMIT IS ISSUED. � �9 `'�( `
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Z I CERTIFV THA71N?HE PERFORMANCE OF TNE NroRK F�R WFIICH TNIS PERMIT IS IS5UED,I MECHANIGAL ,'���J � t�i�✓:_ \ 1
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� SUBJECT TO THE YK1ftKER5'GOMPENSATION PROVISIQkS OF SECTION 37W pF TttE tABQfl `�y (f � /'
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a CONSTRUGTION LENDING AGENGY PRE-ALT FEF:
� I HEpESY AFFIRM UNDEP PENAITY OF PEFJUAY TMAT THERE iS A CONfiTFiUCTiON LENDING AGENCY � � '�
d FOF THE PERf-0RMANC[OF THE WOftIS FOF WNlCH THIS PEftM1T IS ISSUED{SEC.404T,G4.C.J. � —
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� IAGREE TO GOMPLV WITH AL�CI�Y AND COUNTY ORbINANCES AND STATF UWS REtATING TQ 84tL0lNG ! I � � `✓
� LONSTpUCTIQN,ANO HEF&BY AUTHf7RIZE REPRE5ENTATIVES QF THIS COUNTV TO ENTEF UPON THE y„ �. I
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES(ZL)
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APPLICATION DI ti 'A(FIRMLY
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CITY L E V'•G ZITE.
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DESIGNER-
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CITY. ZIF" )TE.
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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(1500).):
DI,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 YEAR OF 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 NOTAPPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHOOONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE 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.
A
517593
LICENSE CLASS
LIC. N0.
DATE 9/3/O1 CONTRACTOR Pulte Homes
WORKERS'COMPENSATION DECLARATION
I HEREB AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS,
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION Sr-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
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE'.
Pacific Employee Ins.Co.
CARRIER
W L1\L 6(13 17
POLICY NUMBER
(MIS SECTION NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS(1700)OR LESSt
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
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
Pulte Homes
5/1/O1
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(1100,000),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- None(Pulte Home Cor)_
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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 INSP CTION PURPOSES.
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PERMITTEE NAME(PRINT)
SIGNA E OF PERMITTEE DATE
APPLICATION PERMIT/C
DATE NUMBER
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DATE CONST. GROUP
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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
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ADDR
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APN LOT TRACT 5-2-26
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OWNER ZV
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APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCHIENG/
DESIGNER
ADDRESS .5/li
CITY ZIPC-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 B (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).):
0 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 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 OF 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).
^ 1,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 NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
W-b CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANT TOTHECONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
(HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT LAM LICENSED UNDER PROVISIONS OF CHAPTER
Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LIC. N0. ?
LICENSE CLASS
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DATE CONTRACTOR
WORKERS
COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
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
ISSUED. MY N'OFyERS'COMPENSATION INSURANC RIER AND
OLICY NUMBER ARE'.
P
CARRIER C--�y�/G!e�i
POLICY NUMBER
(THISSECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE 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
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH T SE PROVISIONS.
DATE:APPLICANT:
WARNING'. FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECTAN 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 WHI THIS PERMIT IS ISSU
(SEC. 3087,CIV.C.).
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LENDER'S NAME JFV��"
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 INSP TION PURPOSES.
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