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CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 &Copley Drive Suite 190
(909) 860 3195 Fax (909) 861.3117
BUILDING PERMIT APPLICATION
' SS
APN_r�3 /`LOT TRAC
(H:{.T
OWNER C/1 ` f Nat i
ADDRۤS 1 -
CITY 1910.1rignA kw).f ZIP TEL < < 2� -- q(405
APPLICANT Y%,' SG 77• ,X� TEL ) 9 14-26CONTRACTOR >
ADDRESS C". I 'V
CITY ZIP TEL 1 _;
ARCKENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIPM UNDER PENALTY OF PFR.URY THAT I AM FYFUPT FROM THE CONTRACTORS t4
CORSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS Ala? PROFESSIONS CODE ANY CITYOR
COUNTY WHICH REQUIRESA PERMIT TO OONSTMICT,ALTER. IMPROVE•DEMOUSL OR RERWIR ANY STRLr,
TURF 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 U -
CENSE LAW (CHAPTER a (COMMENCING WITH SECTION 70DO) OF DIVISION S OF THE BUSINESS AND PRO-
FESSORS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EYEMP•
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 (SSW) -Y.
DI.AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COIPENSA .
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7644, BUSI-
NESS
USH
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR MPROVESTHEREON. AND Y410 DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH MS OR HER —EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUILDING OR MPROYFMENT IS SOLD WITH (NONE YEAR OFOOMPLE.
TON. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALES
D L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED OONT ACTOn3
TO CONSTRUCT THE PROJECT (SEC. 7D44, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LF
CENSE LAW DOESNOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW 4
O 1 AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION 70001 OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC.
DATE �'�� CCNTRA•CTQ(iG ((�•�yf" ��
WORKERTCOMPENSATIONDIC URATION � �T
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLAPATgNS:1� +1,
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR NOR ERS'
COMPENSATION. AS PROVIDED BY SECTION AICD OF THE LABOR CODE FOR THE PERFORMANC
//OF THE WORK FOR WMCH THIS PERMIT IS ISSUED.
�1 HAVE AND WILL UARRAIR WORKERS' COMPENSATION INSURANCE AS REQUIRED BY SECTION
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13
ISSUED. My WORKE(RT COMPENSATION INSURANCE CARRIER AND((POLICY 1' ,`C("IM,
CARRIER v' `• I �i -� �1 L
�..�
POLICY NUMBER
"SECi1g WMNOTSEOMCIUMOFTEPEW ISFORCWHLAPEDD (II(gOR ESSI
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT R ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERTCOMPENSATION P SION aF SECTION 3700 OF THE LABOR
%�SH�U/LR,F�TNITHCOMPLY7 EP ONS.
DATE !s E AN
DATE
WART FAILURE TO /RCURE WDW(ERS' COMPENSATION COVERAGE IS UNLAWFUL ANDS BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FIVES UP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3705 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERPORMANCE OF THE WOK FOR WHICH THIS PERMIT IS ISSUED (SEC 3007, CIV. C).
LENDERS NAME
LENDEFTS ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION MA STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAMS RELATI(t TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE.MENTIONED PROPERTY FOR INSPECTION PURPOSES.
K:NATU PERA0ITFE.; - I GATE
PRESS
FIRMLY
APPLICATIONL j (
PERMIT
/C
DATE
NUMBE
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW ❑
REAR
❑
SIDE(SIDE STREET
RW ❑
SIDE
❑
PROPOSED USE
NO. DWEL NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF ADJ. AREA/VALUATION
SFR(ADD/REM
CD
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ADJ.AREA
QUANTITY DESCRIPTION
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CONSTRUCTION
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INSPECTION FEE
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ENERGY P/C —
ENERGY PERMIT
RETENTION FEE:
PRE•ALTFEE: AGR A 4
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TOTAL FEES
9�•
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COMMENTS
RECPT. N PAID BY
VAUDATION W
WHITE-0epanment Copy. YELLOW -Finance Copy, PINK-ASUnor Copy. GOLDENROD -File COM GREEN -Applicant's Copy
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