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DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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(909)860-3195 Faz(909)861-3117 � ; PRESS
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� IENDEfl'S NAME
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U1,1�IIIXU Ii�1K i
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 n,� �,fy,�
ADDRESS !i �
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APN LOT TRACT
OWNER��I
ADDREyS,S_�"' �
CITY�Iit�� Mt[ZIP TEL.
APPLICANT TEL.
CONTRACTOR�
ADDRESS��
CITY ZIP TEL.
ARCH/EN
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REW IRES A PERMIT 70 CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRNNi TO ITS ISSUANCE.ALSO REWIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED
STATEMENT THAT HE OR :THE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW(CHAPTER 6(IXJMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED E%EMP-
TKKJ.ANY VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).):
^I,AS OWNER OF TH'e 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. 7004,BUSI-
NESS AND PROFESSIONS'OODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY VtIF10 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 E%CLUSIVELY CONTRACTlNG WfFH LICENSED CONTRACTORS
TO CONSTRUCT THE PRO.IECT(SEC. 70H,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(S)LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 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
P(COMMENCWG WITH SECTKNI 7000)OF DIVISKKJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FO iCE AND EFFECT.
LICENSE CLASS� LIC. N0.
DATE�CONTRACTOR�
WORKERS'COMPENSATION DECLARATION
I
AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
T
COMPENSATION.AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOP THE PERFORMANCE
OF THE WORN FOFI WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE N FOR WHICH THIS PERMIT IS
ISSUED. MV WORKEFyS' PfySAT10N INS RF10E CARRI �D POLICY NUMBER ARE:
CARRIER�
POLICY NUMBER
(THIS SECTION NEEC NOT BE(OMPIETID OF7TIE PERNYT IS FOR ONE HUNDRED OOU.AfiS(5100)OR LESS).
I CERTIFY THAT IN'THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SMALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKNJ LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECTT THE V RKERS'COMPENSATKN PROVISIONS OF SECTION 37000E THE LABOR
LADE,I S F
T
HWITH COMPLY WIT E PR'I�9bNS.
/
'I
DATE: -
APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPE ATI COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES IL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f 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
1 HEREBY AFFIRM UNDER F'ENALN OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC. 3097,CIV. C.1.
LENDER'S NAME
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE REPD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY WITH 4LL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-ME TIONED PROPI:RN FOR INSPECTK>N PURPOSES.
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