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_ J� CITY OF DIAMOND BAR J�� ,
+ � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �
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� LENDER'S NAME__._,_ -_ _.
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� I CENTIFY THAT I HRVE REAO THIS APPLICATION AND STATE TMAT TMEABOVE INFORMATION IS COflRECT TOTAL FE ES �
W I�GFlEE TO COMPLV WITH AL�CITV ANO CAUNTY ORDINANCES ANO STATE UWS 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
JOBSITE��I �Cy
QS
y)ci
ADDRESSI�
APN L.OT TRACT
OWNER��
ADDRESS�ta A�
CITY ZIP TEL.
APPLICANT_� �TEL. ��! ���1)
CONTRACTOR��- 1 v k pct%�-'
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ADDRESS�
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CITY%ti � ZIP TEL.
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 UW FOR THE FOLt.OWINO REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRE:.A PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REWIRES 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 UW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAI-HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VgLATION OFSECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT bAORE THAN FIVE HUNDRED DOLURS(5500).):
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7041, BUSI-
NESS AND PROFESSKNS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BURRS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUON HIS OR HER 014N 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 TNAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM E%CLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(5)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE UW.).
^ I AM E%EMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE� OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENGNG WITH SECTON 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
C�
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LICENSE
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��d�'-""CONTRACTOR c
DATE_1L,
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLIOWiNG DECURATIONS:
I HAVE AND WIII MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BVSECTION 37000E THE LABOR GCDE,FOR THE PERFOFIMANCE
OF THE WORK I=OR WHICH THIS PERMIT!S ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE 1A80R CODE,FOP.THE PERFOHMANC OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WC:RKE M ENSAT SURAN CARRIER AND POLICY NUMBER ARE:
CARRIER �
CY
M
R
�a �
POLI
NU
BE
� (IHLS SECTKXJ NEED N07 BE ODIvf�LETED OF TiE PERMRIS FOR ONE HUNDRED DOLLMS(f10D)OR LESS).
I
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
I iHALL NOT EN PLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
�WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TG THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LIBOR
�COOE,I SHALL FOR rHWITH COMPLY WITH THOSE PROVI 5.
�-5�J7
APPLICANT.
t DATE: �
1
F WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COV AGE IS UNUWFUL,AND SHALL BE
1
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLURS(f 100,000),IIJ ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTK)N 370e OF THE LIBOR CODE,INTEREST,AND ATTORNEY'S FEES.
t CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCNON Lc'NOWG AGENCY
FOR THE PER W RMALICE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.J097,CIV.C.).
J
LENDER'S NAME
LENDER'S ADDRESS
�I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY ANO COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
3 CONSTRUCTION,ANCI H EBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED P TY FOR INSPECTION PURPOSES.
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� PERMITTEE N PRINT)//�7 �
r�SIGNATURE P DATE
RITE-Department Copy,YELLOW--Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy