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��_ CITY OF QIAMOND BAR
- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 PRESS
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� CFNSE LAW(CHAPTEh D(GOMMENCING WRH SECTION 7D00)OF DIVISION 3 OF TME BUSINESS AND PRO- 'n Pa
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� NESS AN�7ROFESSIONS CO�E�THE CANTRACTORS LICENSE lAW DOES NOT APPLY l0 AN OWNER OF �
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Q THRd16H HIS OR HER OVM EMCLOVEES.PROVIDED TMAT SUCM IMPROVEMENTS ARE NOT INTENDED OR m
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I HEREBV AFFIRM UNOER F'ENALTY OF vER1URV THAT I AM LICENSE�UNDEF PROVISIONS OF CHAPTER �
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Q 3]00 OF THE LABOF CODE,FOR TiE 7ERFORMANCE OF THE ORK FOP WHICH Tf115 VERMIT IS —
fSSUE�.MY WOAKERS'�MPE ATION INSUR CE CARRI ND PGLIGV NUMBFR ARE: CONSTRUCTION
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W l CERTIfY THAT M TI1E 7ERfORMANCE OF THE WORK FOR WHICH THIS PERMIT 151551JED.1 MECHANICAL
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�,j' SHALLNOTEMPLOYANYPFHSONINANVMANN RSOAS'OBECGMESUBJECTTOTHE �NSPECTIONFEE
� WORKERS'COM�ENSATION LAWS OF CALIFO A,AND AGREE THAT IF HOULO BECOME - J_ —
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J SECTION a1oB oF THE LABOIt COOE.INTENEST,AND ATTORNEY'S FEES. RETENTION FEE: .._
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Q I HERE9VAFFIRM UNOEH PEiJALTY OF PEFJURV THATTHERE IS ACONSTRUCTI�N LENDING AGENCY _
� FORTHE PER�ORMANCE OF THE WORK FOR WMICH THIS PFFMIT IS ISSUED(SEC.3097,CIY.C.).
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w I AGflEE TO CAMPLV WiTH AU.CITV AND CAUNTY ORDINANCES AND STATE IAWS REUTING i0 BUILDING
� C�HSTRUCT!ON,PNO HEREBY WTFbft12E REPRESENTRTIVES OF THIS COUNTY TO ENTEq UPON THE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
ADDRESS-
/^'^'i�^'y^'
APN �-LOT�TRACT
OWNER�(*
ADDRES
CITY hri�Lt-ZIP TEL-
APPLICANT,TEL.
CONTRACTOR �
ADDRESS
CITY_ZIP TEL.
ARCWENG/
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 FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSONS CODE:ANY CITY OR
COUNTY WHICH REW IRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE, PRKM TO ITS ISSIIANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER D (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSKNIS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY YIOLATKJN OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOTMORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF TFIE 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. 70x4. BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY YY/i0 BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OVRJ 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 T11E PROPERTY AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER F'ENALN OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COMMENCING WITH SEC TK)N 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL F E AND EFFECT.
LICENSE CLASS�_� LIC. N0. �� �'L
/^'
DATE�CONTRACTOR j�'�J +c71�
7
W��RKERS'COMPENSATION DE
ARATION
C
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I MER. Y AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL M/11NTAIN A CERTIFICATE OFCONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,A:. PROVIDED BY SECTION 3700 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 REOVIRED BV SECTlON
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE N ORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKE RS�C MPE TION INSUR NCE CARRI ND POLICY NUMBER ARE:
CARRIER �� !%�'-
POLICY NUMBER
(fl-IL55ECTK7N NEOO NOT RE OCMPLETEDOF TFIE PEFiANT IS FOR ONE HIII-DRED DOLLARS(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 MANN R SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFO A,AND A REE THAT IF HOULD BECOME
SUBJECT TOT WORKERS'COMPENSATION OVISIO FSECTI 7000E THE LABOR
CODE,-SHA FORTHWITH COMPLY WITHT PRO SIO
DATE:APPLICANT:
WARNING:ALLURE TO SECL RE WORKERS'COMPENSATION C VER EIS VNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FI P TO ONE HIINDRED THOUSAND
DOLURS(5100,000),IN ADDrfION TO THE COST OF COMPENSATKN. DAMAGES AS PROVIDED FOR IN
SECTION 370D OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PEIJALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CI V.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 HAVE READ TNIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT.
I AGREE TO COMPLY WITH ALL-CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-ME TKKJED PROPERTY FORINSPECTK)N PURPOSEg.
PERMI EE NAME(PRI )J'�^��'JL//
510 R PE ITTEE DAT
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WHITE--OepaRment Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOCDENRC�D-File Copy,GREW-Applicant's Copy
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CITY OF DIAMOND BAR
INSPECTION RECORD
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