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��� CITY flF DIAMOND BAR ��
EP ,4 N O C MMUNITY&DEVELOPMENT;iERVICES ���
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� ADDRESS � '�_C=_(� C.f�`�e���! r " DATEICATION � �� � NUMB R��� #/C
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p t}WNER _�� t;
p ADpRE�'��� /�,�/.�_/"9�-'� L � _ ZONING SETBACKS
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o. ADPRESS UNITS STOR{ES BEDRQOMS
= CITY ZIP TEL. .r
� — DESCRIPTION St�.FL FACTOR PSF ADJ.AREANAIUATtON
Q 4WNER-BUILC}ER DEGLARATION SFRtApt7tREM
0 1 t{fREBY AFFlFW tINOER PENAITY OF PERJl/RY TMAT 1 AM EXGMPT FROM THE CANTRACTORS LI- Gk1f8g0/C3lPQ1t
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W TUF�,PfiKNi TO ITS SSSU.UfCE.KSC�FE9UiRES THE APFLICANT FOR SUGM PERMiT 70 filE A 31C3NE0 �
STATEMENT THAT FiE OR'iHE IS LICENSED PURSUANT TO THE PROVISIONS OF THc CONTRACtOR6 li-
� CEN$E UW(CFIAP'TEN Y QbMMENCINO WITN SEC710N 7W0)OF DIVISION 30F THE BUSME55 pND PRO- � POOVSp3
FESSpNS CODE}OR tHAT HE OH SHE iS EXEAiPT THER£Fft4tAAN6 T}tE 6ASIS FOR THE AIIE{3EC EXEMP�
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� ACML PENAITY 6F NQT A70RE TNAN FNE HUNORED DOI.URS{i500).):
� ❑I.ASOWNEPOFTHEPRbPERIY,ORMYEMPtQY6ESWITNWA4£SASTHEIRSOIECqF1PENSATKd�}. � COmnl8tCi8I
WILL DO THE WORI(,ANb THE STRUC7URE IS NOT INTENDEO OR OFFEPEO FOR SALE(SEC.'l044,BU51- J
HESS JtF�AHOFESSK)HS COQE:ThiE CONTRACTORS LICEN5E LAW DOES N4T MPiY TO AN OWNER OF
� PROPERTYWHOBUILDSf�RIMPROVESiHEREON,ANDWIiOWESSUCHWQRKNiMSELPORHERSELFOR m
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� M1PFpYE FON iHE PURPOSE OF SILLEI.
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� I HEREBV AFF�RM UN�EF;PENALTY OF PENURV TNFT I AM tICENSEO UNDER PR4VISiAYS OF CHAPT�R �/}
� Y�4Y�AMENCINd WITN 91=CTION 7000)OF bIVI5KM130F iHE BUSINES5 AND PROFESSIONS CADE.ANp Z .; V
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N I HEREBV AFFlRAI UNDEN PENAL7Y OF PERJIJRY ONE Of THE FOLIOWING pECUflATroNS: - �1 'j�'
d) � -f , v
� _i NAVE AND W1U.MAtNT,UN ACERTIFICATE 4F GpNSENTTO SELFdN5tlRE FOfl WORKERS' z �. - �t��� �,� ��'
CI�MPENSATIOHI,AS PHOVIpED 9Y SECTIqN 3�0o OF 7HE U@OF CODE,FqR THE PERFORM0.NCE U
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O 3700 O£THE UBOR CODE,1�4R TFlE PERFpRMqNCE O�TNE WC3RK F4 MCYi THiS PERMiT IS
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�}* SNAiLNOT�MPIOYANYPEflSONiNANYMANNER50ASTO8EWMESUBJECTTOTHE
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� DA7E: � APPLICANT: v�`..���`�Ij' "�G_'� SMIP �Q� �... -
� ENERGY P/C y�:¢�,�� .._. _......
WARNINCi:FAIUIFE TO SECURE Wf?RKERS'COMPENSATION GOYERAGE IS UNLAWFUL.AN�SHAIL BE LC�4
iy SUH,tECT AN EMPIOYf'�.it TO CRlIiiNAt PENAlTiES ANb CVVfL F{NES UP TO 9NE#tUNDREO THQUSANQ E�.��F �� 4 Y.,�A��
DpIURS(S1o0,oao),INl�DITION TOlNE COST 4F CAMPENSATION,DAMAvfSAS PROViDED�OR IN �y T �y-�� ��—
� SECTION3�o80fTHCU86RCODE,INTEREST,pNDA7TORNEY'SFEES. AETqr7����,E�J,��I rb:- ,.,�
d GONSTRUCTION LENDING AGENCY pRE-ALT FEE:
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� I HEREBV AFFIqM UNDER PENALTV OF PERJURY THAT7HERE i5 ACONSTRUCTION tENpVNG AOENeY �
FQP THE PERKORMA�ICE OF THE WORN WR WHICH 7MIS PERMIT IS ISSVED(SEC.3oa1,CIV.C.).
W _ _.._�....
� LENOER'S NAME__ _ ^
F�" 4EN�Efl'SADl7f1ES5 ���
� I CERTIFV TNAT I HAVI=REPA THIS APPLICAi ION AND STRTE TNRT THEABOYE INFORMATION ISCORRECT. I UTA��EEt7
� 1 AGflEE TO CCYAVLV iNITH ALL CITV AND COUNTV ORDINANGES ANO STATE UW$RELATIN�T4 BUILpING
C(X�15TFltTCTiOF1,ANG HEREBY AUTHOflt2£FIEPRESEPITATVYES Oi THIS CAUNTY TO ENTEfl UPON TNE
�'�'. ABOVE•MEHTK?NED FROPERTv FOFI MSpECTION PURPOSES. COMMENTS _..
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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 PERMq APPLICATION
Pik*1
PRESS
FIRMLY
APPLICATION/�
PERMIT/C
/
DATE/NUMBER#
ISSUE OCC
P
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DATE Z/
0
N
ST GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
U) Garage/Carport
w Patio/Deck
L.I
PooVSpa
Re-Roof
IJ Commercial
I
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
a s ,1 ?
W f
W
Z S..
J ft/L G CO
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
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MECHANICAL A\{f
INSPECTION EA
ISSUANCE S
SMIP AAAAAA
ENERGY BAK
EN DF"'-y
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RET[ 1t115EE1NGJJALl4
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
JOBSITE
1
K1
11
APN LOT TRACT 7
OWNER G C-
ADDRESS-
CITY kE'IPf TEL,W.S w2 f
APPLICANT TEL.
CONTRACTOR y£ �Y6/
ADDRES�;
CITY/ZIP TE 2-
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 LAW FOR THE FOLLDW ING REASON(SEC 7031.5 BUSINESSAND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMrTTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH. OR REPAIR 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-
FESSIO NS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
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($500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND 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 OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF 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 EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW 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 CONTRAC.
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDEF PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE IS IN FU PPRCE AND EFFECT.
7
LICENSE CLASS � LIC. N0.
DATE CONTRALTO
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL_MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FO HICH THIS PERMIT IS
CSAT INSURANCE CARRIER AND PQ V NUMBER ARE:
MV WC RKE�COM
AR IER
- 271-
L4y
/1
^' ry^'j
e!2 7-- �
/
POLICYNUMBER
r
�
(THIS SECTlON NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE HIN-CREDDOLLARS(5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTlON 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH T SE PROVISIONS.
APPLICANT
DATE:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),I11 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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.C.).
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 ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.ANC HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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RMITT AME(PRINT)
RE OF PE EE DATE
WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
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