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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 PERMIT APPLICATION _
JOBSITE
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APN LOT TR CT
p OWNER
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WE CITY L IPI 4 TEL. 1
S APPLICANT TEL.
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17 CITY ZIP TEL.
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z' DESIGNER
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CITY ZIP 26A TE DO
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D� OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI.
W CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONSCODE'ANY CITY OR
ZCOUNTY WHICH REQUIRESA PEflMITTO CONSTRUCT,ALTER, IMPROVE. DEMOLISH, ORREPAIR ANYSTflUC-
LLJ TUBE, PRKM TO ITS ISSUANCE, ALSO REQUIRES 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 O (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
J TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANTTO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500),):
01,AS OWNER OFTH-e PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
Z VALL OO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, SUSI-
NESSAND PROFESSKXNS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. ANO WHO DOES SUCH WORK HIMSELF OR HERSELF OR
L THROUGH HIS OR HER OWNEMPLOYEES, PROVIDED THATSUCH IMPROVEMENTS ARE NOT INTENOEDOR
OFFEREDFORSALE IF, HOWEVER. THE BUILDING OR IMPROVEMENT IS SOLDWITHINONE YEAR OFCOMPLE•
Z TION, THE OWNERAUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE].
1J
O I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
i
TO
CONSTRUCT
THE PROJECT (SEC. 7040. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U -
JJ CENSE. DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACCNTRACTORIS) LICENSED PURSUANT TOTHE CONTRAC-
TORSIJCENSE LAW.).
? ❑ 1 AM EXEMPT UNDER SEC. B. S P.C. FOR THIS REASON
i DATE
� _— OWNER —
4� LICENSED CONTRACTORS DECLARATION
L 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
]- 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
�LCJ MY LICENSE IS IN FULL FORCE AND EFFECT. ;
_ l?0 -
LICENSE LIC. NO.
J DATE+ 4CfayCONTRACTOR _ _—
a WORKERS' COMPENSATION DECLARATION
n 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
n
— I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-IN8URE FOR WORKERS'
GS, COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
U
—__ 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOWRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WH ICH THIS PERMIT IS
J ISSUED. MY WO CERS'COMPjEENNSATIONNIINNSSURRANN�CE,CARRIER
�AND
lPOLICY NUMBER ARE:
a
CARRIER
_-L%I+"-._—L'" �Ji(.'/C.-/'1 M(✓ G __ __—_ _.. _—
POLICY NUMBER
/ wo=
] (THIS SECTION NEED NOT BE COAPI-ETED OF THE PERMIT B FOR ONE HUNDRED DOLLARS Woo) OR LESS).
Ll
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
5 SHALL NOT EMPLOY ANY PERSON IN ANY S TO BECOME SUBJECT TO
q
WORKERS 'COMPENSATION LAWS OF CAlIFO. IA, AND EF THAT IF 611 LD
I
SUBJECT TO THE WORKERS' COMPENSATION OVISION F SECTION 37000E T
] COUE,ISHALL FORTHWITH COMPLY WI ONS. - dt
] DATE: APPLICANT: JJWARNING: FAILURE TO SECURE WORKERS'COMPF TION COVERAGE IS UNLAWFUL.ANSUBJECT AN EMPLOYER TO CRIMINAL PENALTIF CIVIL FINES UP TO ONE HUNDRED TDOLLARS(;10D,000),IN ADDITION TO THE COS F PENSATION, DAMAGESAS PROVID
J SECTION 3708 OF THE LABOR CODE. INTER ATTORNEYS FEES.
C
CONSTRLf ION LENDING AGENCY
C I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LCNOING AGENCY
L FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. C.).
u
C LENDER'S NAME
LENDER'S.10DRESS
C I CERTIFYTHAT 1 HAVE READ THIS APPLICATION ANU STATE THAT THF. ABOVE INFORMATION IS CORRECT
J I AGREE TO AT
WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HERESY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
J_
] PERMITTEE NAME (PRINT) fu
7 �
O SIGNATURE OF PERMITTEE DATE J
PRESS
FIRMLY
APPLICATION Z /�j -3 P/C
DATE ,r� � � NUMBEE R _(,°°!•' #
ISSUE OCC
TYPE
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR r
SIDE/SIDE STREET _ RW p
SIDE
PROPOSED USE y f
NO. DWEL. NO. NO
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
W
Patio/Deck
V-
0
PooVSpa
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Re -Root
Commercial
CD
Valuation % A. ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
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MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE: el
TOTAL FEES
COMMENTS__.,_
RECPT, NO �— �
PAID BY VALIDATION
r'Ini I c—veparmlanL �apy, TCLLuw—rtnanca copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy