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CITY OF DIAMOND BAR
- I7EPARTMENT OF COMMUNITY&DEVELOPMENT 3ERV[CES
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� AQDRESS DATE ��r� NUMBER J # t {
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� awNE� Diamond Bar We�t. LLC__
p ADDRESS 3480 Torrance Blvd. Ste, 300 ZONING ETBACKS
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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 PERMTT APPLICATION
I.r�!�'i:(:
PRESS
FIRMLY
JOBSITE
2800 CRYSTAL RIDGE ROAD
ADDRESS
APN LOT 29 TRACT 47850
OWNER Diamond Bar West, LLC
ADDRESS 34!30 Torrance Blvd. Ste. 300
CITY Torrance zIP 90503 TEL.31G-540-399
APPLICANT Rll,�rd Gould TEL. SalLle d�OVe
CONTRACTOR JCC Construction
ADDRESS same as owner
CITY ZIP TEL.
ARCH/ENG/
R.Gould&Assoc.__
DESIGNER
ADDRESS same as owner
CITY_ZIP_TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERDU RV THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON (SEC. 70315 BUSINESS AND PROFESSIONS CODE:ANV CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPP.IR ANY 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 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 ANC THE BASIS FOR THE ALLEG ED EXEMP-
TION.ANY VKK.ATION OF SI CTION 7031.5 BV ANV APPLICANT FO?A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(55001.).
�I,AS OWNER OF THI: PROPERTY,OR MV EMPLOYEES W ITN WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK.AND'fHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7064, BUSt�
NESS AND PROFESSIONS IbDE:THE CONTRACTORS LICENSE I AW DOES NOT 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, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE-IF HOINEVER THE BUILDING OR IMPROVEMENT IS SOLD W I7aIN ONE YEAR OF COMPLE-
TKKJ,THE OWNER-BUILDER WILL HAVE THE BURDEN OF RPOVING THAT HE OR SHE DIO NOT 9UILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PRO.IECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT AP�LV TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS W ITN A CONTRACTORI51 L!CENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW).
^ I AM EXEMPT UNDER SEC. H. R P�. FOR?MIS REASON
DATE OWNER - - - - -
I ICENSED CONTRAC?ORS DF C1.ARATION I
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM I.IC�cNSF:D'.'N'iF!i PROV:S 4'�NS OF(; h1APTFR
D(COMMENCING WITH SECTION 7000)OF DIVISION :+OF-HE PUSnv E95 AND?ROFESSIGNS CODE.AND I
MY LICENSE IS IN FULL TC'RCE AND EFFECT.
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DATE -CONTRA
.TOR
WORKERS'COMPENSATfON DECLARATION
I HEREBY AFFIRM IINOER PENALTY OF PERJURY ONE OF THE FOI I OWINC; Df-C'.ARATION :.
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF�INSURF. FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 3701 OF THE LABOR('ODE. FOR THE PERFORMANCE
OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED. 1
XI
-INANE AND WILL MAINTAIN WORKERS'COMPENSATION INSIIRANCF.AS'2E0'JIRFD RV SECTION
37000E THE LABOR CODE, FOR'fHE PERFORMANCE OF THE WORN �0°.W4I^,H THIS- P[PMiT I.5
AN
C POLICY NUMBER ARt:
OP KERS'CAMPENSATION INSURANCE CARPIER
ISSUED. MY W
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CARRIER SU e Z��SL�R li rAll�t C e . �.0�
POLICY NUMBER -
(INLSSECIK)N NEIL NOT BE CC•.PLETED OF THE PFRNUT IS FOR ONE HUN'iRFD OJCLAR5131001 OR LESFL
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 1 H'.S PE HMIT'S ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANtI MANNER SO AS TO BECOME SUBJEC L TO THE
WORKERS'COMA>ENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF;SHOULD 9ECO1.lE
SUBJECT TO THE:WORKERS'COMPENSATION PROVISIONS OF SECTION 37no OF TFI'r. LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE:APPLICANT - -- .- - -
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNV WFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES DP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPEN SATiON. DAMAGES AS PROVIDED FOR IN
I SECTKIN 37080E THE. LABOR CODE.INTEREST ANO AT'-ORNF V'S FEES.
I CONSTHi1CT10N LENDING AGENCY
i
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT-MERE IS A CON.STRIICTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WNIC:H THIS PERMIT IS ISSUED ISEC. 3oe7.CIV C.1.
1
LENDER'S NAME �
LENDER'S ADDRESS - - - -
I I CERTIFY THAT I HAVE READ THIS APPLICgTION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE IAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESEM ATIVFS OF THIS COUNTY TO EN fER UPON THE
1
ABOVE-MENTIONED PROPERTY FOR INSPECTION PIIRPOSF.S.
1
i PE ITTEE NAME(PRIIJT)
�SIGNATURE OF PERMITTEE DATE
WHITE-Dap2rtment Copv.YELL OW---F inanca Copv. PINK-Assessor Copy. G1�LDENROD-File Copy. GREEN-Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
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a �v� .Z
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INSPECTION DATE INSPECTOR
�!L JOIST
FHA REQMTS
47L DUCT
LVIL.2� OOR
00 F- FLOOR CO1�1�6�=IT�
ACE: FOUNDATION
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