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CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
�,. 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION.
JOBSITE
i ADDRESS2 `
APN LOT TRACT
OWNER C_A%Z L ti r O GL 0"-4,& L_f S
ADDRESS Z 415 OA912-11I DZW6
CITY 91A"Or4a BAP— ZIP TEL. &�/ s/49
APPLICANT Lt/Vti TEL. 4TS-6466
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCWENG/
i DESIGNER
ADDRESS
CITY ZIP TEL.
i
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE
FCENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT:ALTER, IMPROVE. DEMOLISH, OR REPAIRANY STRUC-
TURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED
STATEMENT TRAY HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION TODD) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS 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 SUBIE CTS THE APPLICANT TO
A CIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (55(0).):
Ll 1, AS OWNER OFTHE 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, SUSI
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 15 SOLD WITHINONE YEAROFOOMPLE-
TION, THE OWNER43UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
13 I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. TDAN. 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 WITHACONTRACTOR(S) LICENSED PURSUANT TO THE OONTRAO
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. _ B. 5 P.C. FOR THIS REASON
DATE ?5�_ OWNER It_ ^
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OFCHAPTER
9 (COMMENCING WITH SECTION 7") OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS _ LIG. NO.
: DATE _ CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBYAFFIRM 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.
`1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER _.._
POLICY NUMBER
(THIS SECTION NEED NOT BEOJt.1PLETEDOF THE PERMIT B FOR ONE HUNDRED DOi1MS MOO)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 CAL IFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: _ APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBIECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND
DOLLARS (SIOO.000). IN ADDITION TO THE COSTOF 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 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 R"TING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHomzE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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''SIONANflE OL�
PRESS
FIRMLY
APPLICATION 3/'7 ( PERMIT /41 d d a P/C
DATE
NUMBERISSUE #
/
DATE X312 / / f/'� yl TYPE OCC
GROUP
,CONST.
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDESTREET RW ❑
SIDE ❑
PROPOSED USE ROOM 4 DOt T (O(.a.
NO. DWEL. NO. NO.
Z 3
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT FACTOR PSF ADJ. AREANALUATION
'., CD
Garage/Carport
W:Patio/Deck
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QUANTITY DESCRIPTION FEE
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,TION _
PLAN REVIEW
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE 15ej•
SMIP ®• r.�O
ENERGY P/C
ENERGYPERMIT
RETENTION FEE: Z- ` 2
PRE•ALT FEE: _
TOTAL FEES
COMMENTS
RECPT. N0. C/-° ; PAID BYxVALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy `�,