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1 CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 561-3117
BUILDING PERMIT APPLICATION
JOBSITE --I Or
ADDRESS
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APN O a RACT
OWNER
ADDR
CITY %Aym A ZIP TEL.
APPLICANT TEL.
CONTRACT R _
ADDRE S ell
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS L4
CENSE LAW FORT IE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUO
TUBE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO TI IF PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) 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 FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($5001):
O 1, 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 HERSEt.F 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 ONEYEAROFCOMPLE
TION, THE OWNEH-BUILOER WILL HAVE THE BURDEN OF PROVING THAT HE, OR SHE DID NOT BUILD OR
IMPROVE FOR THE. EDRPOSE OF SALE).
❑ I,AS OWNER OFTHE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LF
CENSE LAW DOES NOT APPLYTO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. B. & 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
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE N " CONTRACTOR
RKERS' COMPENSATION DECLARATIO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: j
fl
—I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FDR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
t OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37000F THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKS 'CO P SATI INSU CARRI AND POLICYNUMBERARE:
CARRIER
POLICY NUMBER —
(MtSSECT)ON NEED NOT BECCMPLETED OF THE PERMIT IS FOR ONE HUNDREDDOULARS (SIJILE71.
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
WORKERSCOMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECT 3700 OF THE LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH PROVISIO
DATE/a= APPLICANT: -
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), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENAI TY 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 RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY T TE PO) THE
ABOVE -MEN D PROPERTY FOR INSPECTION PURPOSES.
PERMI E (PRINT)
S A7UR O PERMITTEE - DATE
PRESS
FIRMLY
APPLICATION �PERMITP/C
DATE NUMBER #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW fl
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE V
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ..AREAIVALUATION
SFR/ADD/REM
Garage/Carport
WLUPatiolDeck
U-
Pool/Spa
ZRe
-Roof
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Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION • O`.:+
PLAN REVIEW
ELECTRIC
PLU�a*��I
MECH
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ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
•
RECPT NO.uv ID 8Y ALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN -Applicant's Copy
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