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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
ADDRESS tel/ E/rlil� NEs! 4
APN LOT 3 2 TRACT
OWNER
ADDRESS
CITY ZIP L7 r TEL
APPUCANT TEL
CONTRACTOR
ADDRESS
CITY-- — -- -- -- -- ZIP- — -- --TEL---*---"'
----- - -.
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTACTORS U.
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AIM PROFESSIONS COOS ANY CRY OR
COUNTY WHICH REQUIRES PERMIT TO CONSTRUCT,ALTER MPROVE,DEMOIWI, OR REP" ANY STRUC•
TURF. PRIOR TO ITS MUA14CL ALSO REOUIRES 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 6 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) ORTAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FORTHE ALLEGED EXEMP•
TION. ANY VIOLATION OF SECTION 7031.6 BYANY APPLICANT FORAPERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF HOT MORE THAN FIVE HUNDRED DOLLARS (ISM) T
0 L AS004ER OF THE PROPERTY. OA MY EMPLOYEES NTH WAGES AS THEIR SOLE COMPENSATION,
WILL W THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FDR SALE (SE4 704, BUST
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WTO DOES SUCH WORK WMSELFOR HERSELF OR
THROUGH HIS OA NEA OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPIE-
TION, THE OWNERSULDER WILL AVE THE BURDEN OF PROVING THAT HE OR SHE DD NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEM
0 L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WAR LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 704. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI
CENSE LAW DOES NOT APPLY TORN OWNER OF A PROPERTYWHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTOTNE CONTRAC-
TORS LICENSE LAW). -
O IAM EXEMPT UNDER SEC. B 3 P.C. FOR THIS REASON
DATE OWNEVQ
LICENSED CONT ORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
B (COMMENCING
G WITH SECTION 7000) OF DIVISION 3 O THE SUSWESS MID PROFESSIONS GODL AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS LIC NO.
DATE CONTRACTOR
I
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PEAJIURY ONE OF THE FOLLOWING DECLARATIONS:
_I AVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 37M OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. ..
I AVE AND WILL MAINTAIN WOR(ERLT COMPENSATION INSURANCE AS REWIRED BY SECTION
37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORT( FOR WHICH/ TIUS PERMIT IS
ISSUED. MY WORKERS' COUIPENSATION INSURANCE CARRIER AND POLICY "ISEAARE
CARRIER
POLICY NUMBER
(MUCIICN NE®NOTBE OOLP.LTEDOFTHE PEAL S FORCNE W"MM=ARS(IIgCRLESS1
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THUS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WOWAS'COMPENSATION LAWS OF CALIFORNIA, 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:
WAANINO: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER To CRaINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($Ioo.=L N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR W
SECTION 3706 OF THE LABOR CODE. INTEREST." ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IR ISSUED (SEG MT. DIV. CJ.
LENDERS NAME
LENDERTSADORESS
1 CERTIFY THAT 1 RAVE AM THIS APPLICATION AND STATE TATTHIE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDDANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THS COUNT' TO ENTER UPON THE
#IENiONED PROPERTY FOR INSPECTION PURPOSES.
W
P ENAME(PRPN)
OF PEAWTTEE DAT •(
PRESS
FIRMLY
APPLICATION ��� PERMITo� P/C
NU
DATE MBER x
ISSUE // d/ 7 TYPE OCC -
DATE CONST. GROUP
(
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDESTREET RW ❑'
SIDE ❑
PROPOSED USE
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM 1?
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QUANTITY DESCRIPTION FEE
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