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-.�'�.. _ GITY OF DIAMi7ND BAR �--'�,i ,
DEPARTMENT OF COMMIJNTTY 8t DEVELOPMENT SERVICES �
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{9(19)860-3195 Fa�c(909)861-311? ,r� 'ti �� �r �S�
��'""'� BUILDING PERMIT APPLICATIUN � �IRMLY
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� CENSE LAW(CHAPTER Y(COMMENCIN9 WITH SECTION 700a)OF OIVISION 3 OF TME BUSINESS AND PAq� � PoaU6pa
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NESS AND PpOFE5SIONS fI1DE:THE CONTRACTORS LICENSE LAW OtlES NpT APPLV TO AN OWNER OF
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p„ 9(CQAIMENCWO WRH SECTNNJ�o00)OF DIVISION 3 OF THE BUSiNE55 AND PROFESSIONS CODE,AND Z
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OF TNE WOPK FOq WHICIi THIS PEFIAIT IS ISSUED. �
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Q 37000F THE tA80R GOOE,FQft THE PERFORMAFlCE OF THE WORK F7R WNICH 1'NIS PERMIT IS
�SSUED.MY WOFlKERS'COMPENSAiION iNSURANCE CARRiER AND i�OLiCY NUtiB£R AAE: GCYNSTRUCTION
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ZP6LICV NUMBEP ELECTRIC � �
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Z I CERTIFV THAT sN THE PERFORMANCE OF THE WOPoC FOR WHICH TNiS PERMiT IS iSSUED,i MEGHA�IVCAL
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� 1�RNERSCOMPENSATKK3IAWS�CAt.iFORNiAPNDAGREETriA?IFt5NOULp9ECOME INSPECTIONFEE
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LL SU0.IECTANEMPLOVEFITOCRIMINALPENpLTIESANDCIVILFINESUPTOONEHUNDREOTHOUSAND ENERGVPERMIT
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� SECTqN 31oe OF THE LABOR CODE,INTEREST.AND ATI'qRNEV'S FEES. F�ETENTION FEE: r1
aW. CONSTRUCTIpN IEND�NG AGENCY �
PRE-AlT FEE:
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� I HEREBY AFFlRM UND4�R PENAtTY QF PEpJURY 7HAT THEFiE I$ACGINSTRUCTtON lENpiNG ApEt�Y _
FpR THE PEflF(?RMANf:E OF THE WOFK WR WHICH TN�S PERMIT IS ISSUEQ(SEC.3981,CIV.G).
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� LENOER'6MAME„_,_
I=- LENOER'SADDR£SS_ �s� �-T—
� TOTAL FEES
� t CERTIFY THA71 HAYE READ THIS APPLICATI4N Ati6 STATE THATTH6 AHOYE MIWPMATION IS CQflRECT.
W I AOREE TO COMPLV WITH A4L CRV AND COUNTY ORDINANCE9 AND S7ATE IAWS RELATING TO BUIIDING r
� CCNJSTRUCTION,AND NEREBV AVT410RRE REFRESENTATNES OF THIS CAUNTY TO ENTER UPON THE
� A8(?Vf-MENTpNEDPF4dPERTYFORtNSP�CTtONPtXiPOSES.
z COMMENTS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
HACF
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CRN 40LLe13 PAL-
ADDRESS
lAHWe
APN LOT TRACT
OWNER MR kR s J ;A J o MP&,a ; LLJ2A JAI
ADDRESS It,L o
q I TEL. �•-. D
CITY 1 )a'ZIP
APPLICANT IA'Scl.,l l Nt..t pJ .r_TEL C
CONTRACTOR�,u''/Crt/0.,,00
ADDRESS
CITY ZIP TEL.
ARCFVENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE. PRIOR 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 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 FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
D I.AS OWNER OF THE: PROPERTY. OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORT.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 HERSELF 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 ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
D I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
D I 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. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
-1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTlON 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
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBED
(OHS SECTION NEED NOT BE ODNIPLETED OFTFE PERMIT IS FOR ONE IBJPORED DCLARS($100)OR LESS}
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
WORKERS'COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THIS WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYEFI 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.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION 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 TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERMITTEE NAME(PRINT)
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7 SIGNATURE PERMITTEE DATE
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APPLICATIO 1 PERMIT c P/C
DATE 14 G J NUMBER I ( J � / #
ISSUE TYPE )CC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE
N0. DWEL. N0. ' N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Garage/Carport
LI Patio/Deck
L
LL Pool/Spa
Z Re-Roof
Commercial
5
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
LU
W
0
Z
M
EL
Z
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID B VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy