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�'�r�; DEPARTMENT OF COMIvTIJNITX&DEVELOPMENT 5ERVICES
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CITY OF DIAMOND BAR
DF,PARTMENT OF COMMUNTfI'&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE y9�2�
ADDRESS�E�I��/LO.�1fl.GJ,�Q/d
APN LOT TRACT
OWNER
ADDRESS- � �Z> r
CITY�-��tk ZI TEL.
APPLICANT�TEL.
CONTRACTOR_
ADDRESS
CITY ZIP TEL.
ARCH/ENG/�� �, �_��
DESIGNER� �44�C,��-C�
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE.ANY CITY OR
COUNTY WHICH REOUIRESAPERMIT TO CONSTRUCT,ALTER. IMPROVE. DEMOLISH,OR REPAIR ANY S7RUG
TUBE. 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((:OMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF S ECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT NORE THAN FIVE HUNDRED DOLLARS(2500).):
0 I,AS OWN ER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK,AND'fHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 704d, BUSI-
NESSAND 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 OWIV EMPLOYEES. PROVIDED THAT SUCH IMPgOVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF,HOYVEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE V EAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPO:iE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJcCT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFq PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER
S
EC
. B. 8 P.C. FOR THIS REASON
)
)
DATE�'� � OWNER
LII�ENSED CONTRACTORS D LARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTEq
9(COMMENCING WITH SEC110N 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECIARATK)NS�.
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOFI WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3]00 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 BV SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKEFIS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(t}il5 SECTK]NNEOO NOT BE LL7MPLETED OF THE PERMR LS FOR ONE HINDRED DOLLARS(5100)OR LESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANV MANNEq 50 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 37000E THE LABOR
CODE,I SHALL FORTFIWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT
WARNING: FAILURE TO SECUFIE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
UOLLARS(t100.000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37080E THE LABOR CODE,INTEREST,AND AT70RN EYS FEES.
(CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.CJ.
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 ALI CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERT��FOR INSPECTION PURPOSES.
PERMITT NA(PRI T)I 0
_/fJ �-JL
SIG OF PERMITTEE- DATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
PRESS
FIRMLY