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�� CITY OF DIAMOND BAR ,
DEPARTMENT OF COMMUNITY & DEVM'0 7.fflcE
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
, BUILDING PERMIT APPLICATION IRMLY
ADDRIESS �35 AAL N �5 I
APN LOTr TRACT
OWNER 4rkGUJ 9—ei 1, 'J'
ADDRESS 3'> E
CITY Dit o ZIP °1ni TEL. qD i fel-D-21n�
APPLICANT Ui TEL. 31.'S '1 L'J • 1l T n
CONTRACTOR i1 1 -?T t Ys(LU(
ADDRESS—W-"
CITY c ZIP ChTEL'gDtl
ARCWENG/
DESIGNER
ADDRESS -
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFF84i UNDER PENALTY OF PENURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7091.6 BUSINESS AM PROFESSIONS CODE ANYCTYOR
COUNTY WHI04REW WESAPERMR TO CONSTRUCT,ALTER IMPROVE. DEMOLISH, OR REPNRANY STRW
TURF PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO ME A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS OF
CENSE LAW (CHAPTER 0 (COMMENCNO WITH SECTION 700D) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) ORTHAT HE ORSNE IS EXEMPT MEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
ACRAL PENALTY OF NOT MORE TWIN FIVE HUNDRED DOLLARS (I SUD)J:
O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES MOM WAGES AS THEIR SOLE COMPENSATION,
WILL 00 THE WOWR ANO THE STRUCTURE IS NOT INTENDED 09 OFFERED FOR SALE (SEC. 7044, SUSI-
NESS ANO PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO WILDSOR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUON 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 ONE YEAR OF COMPLE-
TION, THE OWNER -WILDER WILL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEM
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WRTL LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG Tao. BUSINESS AND PROFESSIONS COOS THE CONTRACTORS LF
CENSE LAW DOES NOTAPPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)UCENSED PURSUANT 70 THE GONTRAO-
TORS UCEHSE LAW.}
O IAM EXEMPT UNDER SEG B t P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (ODMMENCNO WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE. AND
W LICENSE IS IN FLU FORCE
2AND
�EFFECT.
UCENSE CLASS 1 LI 7 1'1 UC. NO. v�
ELITE (6 ' 1'{� CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PER JRY ONE OF THE FOLLOWING DECORATIONS:
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WORKERS
COMPENSATION. AS PROVIDED BY SECTION 37000E THE LABOR COOS, FOR THE PERFORMANCE
OF THE WORK FOR WINCH T" PERMIT IS ISSUED.
I HAVE AND WILL MARIAN WORKERS' COMPENSATION INSURANCE AS REQUIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
COMCAFiRI RIMY �RI(E f�P k1UATION CARRIER AND POLICY HUMBER ARE
POLIGY NUMBER; l/7�/�_n��1(�- n 4 ,
(H(sSEcnONNEEDNOTSEMU ETOOFTHEPUWr.FDRCN KMtD(X IAFS,,$IOD)CRLESSI.
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS 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 FORTHLWRH COMPLY WITH Rove IaNs.
I j�
DATE APPLICANT.=*
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO CNE KMDRED THOUSAND
DOLLARS IS100,00q. IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE L.ABOH CODE. INTEREST. AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
1 HE RELYAFnRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH TINS PERMIT IS ISSUED (SEG 3007• GK C.I.
LENDER'S NAME
LENDERS ADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
IAGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTOfl AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
e reed
SIGNATURE OF PEAMITTEE DATE lU!
APPLICATIONn _ q 8 PER IT 1,�q j PIC
DATE b
ISSUq. OCC
D TE r/ I 19 COPE T GROUP
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ZONING SETBACKS
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PROPOSED USE ii.(i [1 CL
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NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
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QUANTITY DESCRIPTION FEE
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ENERGY P/C
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RETENTION FEE:
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TOTAL FEES
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COMMENTS
RECPT. NO. PAID BY Q VALIDATION
WHITE -Department Copy, YELLOW --France Copy. PINK -Assessor Copy. (iULULNRUU-tile LOPY, L;Httn-APP4=U 9 L:op)r
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