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_ _�,�� CITY OF bIAMONLl BAR '�l.- �
DEPARTL4ENT OF COMMUIriITY&DEVELOPMENT SERVICES /,
21660 E.Copley Drive Suiu 190 � pRESS
I (909}8bti-3195 Fax(4tf9}861-3117
( ��"��� � BUILDING PERMTI'APPLICATION FIRMI.Y
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WII,L DO THE WORK,AND THE STRUC7URE IS NfST INTENDED OR OFFEREp FOF SALE(SEC.76�a,BUSI- �I
� NE55 M10 PtiORESSKM75 CODE:7HE CONTNACTqRs I.ICEtiSE UW'J�ES NOT APPIY TO AN OWMER oF =
PROPEfiTY YVI4D 6URG8 OR IMPROVES 7HEREON,AND WHD�OES SUCH WK1RK HIMSELF Ofl HEtiSELF Ofi .
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� SUBJECT rW£MPLGVER iC5 GRIMiNAL P£NALTfES AN6CN�l RNES UP E HUNQRE6 TtKK7SAN0 ENERGY PERMIT _, .
DOlLARS(f100.000),IN ApDITION TO THE COST OF CAMPENSATIpN, AGES AS PfiOVIDEp FOR IN
� SECTRNI37080F TtiE tAB�R CODE.MTEREST,ANDATTORNEY'S FEES. AETENTION FEE:
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� CONSTRUCTION LENpING AGENCY PRE-ALT FEE: __._.v ---
� I HEREBV AFFIRM Uv�ER PENALTY OF PERJUflv THATTHERE IS ACONSTRUCTION LENDINQ AGEN(:Y ? �� . �
FOft THE QEftFOHM0.NCE OF THE WORN f-0fl WNICH 7HI5 PEPMIT IS ISSUEO(SEC.3PB7,CIV.C.�. � .i 1
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CITY OF DIAMOND BAR
DEPART?4ENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)8b1-3117
BUILDING PERMIT APPLICATION
JOBSITE�J�/�'
ADDRESS����, �i'�/CO�JS IG'��J�",
APN t 0�TRACT
OWNER G,Q/'/.�i,
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ADDRESS�5� !7o L L�/�Cv/�S !� �/'4
CITY 1.11 o A+Rf-ZIP TEL.G�9/1 �0 8
APPLICANT�: U o 3'TEL.!-���s 3g,�
CONTRACTOR� 1•er� oD�SP�9
ADDRESS I!/! 1 f w�I
CITY/�1K� �g-ZIP ! a2 TEL.
ARCWENG/n
DESIGNER�re���N��I'to�y��/�„
ADDRESS 6,I�/Lr' IVo�f+Fir�S
csr ZIP/ 1 TEL
CITY G 14Kr�
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OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FORTME FOLLOWING REASON(SEC.7o37.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRESA PERMfT70 CONSTRUCT,ALTER IMPROVE, DEMWSH,OR REPAIRANY STRUC-
TURE. PRgR TO ITS ISSIJANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFIOVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSXNISCODE)OR T}UIT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VKXJ�TX)N OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANT TO
ACML PENALTY OF N07 MORE THAN FNE HUNDRED DOLLARS(f500J.):
^ 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
MALL DO THE WORK AND THE STRUCTURE IS N07INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSK7N5 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO KURDS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
7HRWGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERW FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMEN7IS SOLD WITHIN ONE YEAROF COMPLE-
TION,THE OWNER-BUIUJER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNEROF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WIT}{LICENSED CONTRACTORS
TO CONSTRUCT THE PFK?IECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUiL05 OR IMPROVES THEREON,AND
WHO COMRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B.f P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THA71 AM LICENSED UNDER PROVISKNJS OF CHAPTER
o(COMMENCING WITH SECTION 7000)OF DIVISKXJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE 5 IN FULL FORCE AND
EFF
ECT.
LICENSE CLASS_�,J� LIC. N0. �//D�
DATE CONTRACTOR�'A/1 C/� �S
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNC ER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLAMTK)NS:
I HAVE ANDWLLL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COIAPENSATKNJ,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK; FOR WHICH THIS PERMIT IS ISSUED.
��
I 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
RANCE CARRIER AND POLICY NUMBER ARE:
SATION INS
U
ISSUED. MY M/OR
KERS'COMPEN
J
7
/
CARRIER_C�A/C�0� !"
./
! POLICY NUMBER G� ��S'1 [v
�(1}15 SECTpM NEED N07 BECOMPLETm OF 7IiE PEFPATSFORONE HUrJDRED DCIlARS(ftOD)OR LESS).
I
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
i SHALL NOT E MPLOV ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
j WORKERS'COMPENSATKX7 LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROV IONS OF SECTlON 3700 OF THE LABOR
{CODE,I SHALL FORTHWITH COMPLY WITH THOS OVISIONS�
1
)DATE: �APPLICANT:
1 �
7 WARNING: FAILURE'TO SECURE WORKERS'COMPENSATION COVERAGE IS LAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP NE HUNDRED THOUSAND
DOLLARS(f 700,000),IN ADDITION TO THE COST OF COMPENSATION,AGES AS PROVIDED FOR IN
1 SECTK)N 3708 OF TI{E 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.).
1
LENDER'S NAME
LENDER'S ADDRESS
�I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND CWNN ORDINANCES AND STATE LAWS RELATING TO BUILDING
s CONSTRUCTK7N,AND HEREBY AUTHORIZE REPRESENTATIVES OF THISCWNTY TO ENTER UPON THE
ABOVE-MENTKNIEI7 PROPERTY FOR INSPECTKNI PURPOSES.
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