HomeMy WebLinkAbout15598 ��� CITY OF DIAMOND BAR
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� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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(909)86Q3195 Fax(909)861-3117 PRESS
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21660 E.Copley Drive Suite 190
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OF THE WORK FOF WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH TFIIS PERMIT IS
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(TWS SECTION NE'J NOT BE O:Jb1PLEfID OFTHE PERMIT 6 FOR ONE HIMDRED COLLARS 8100)L�,
I CERTIFY THAT IN'fHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU D. I
SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'CCMAPENSATKNJ LAWS OF CALIFORNIA,AND AGREE THAT IF i SHOULD BECOME
SUBJECT TO THE VIORKERS'COMPENSATION PFIOVISIONS OF SECTION 3700 OF THE LABOR
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WARNING: FAILURE TO SECURE WORKERS'COMPENSATION (OVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),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 F'ENALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CI V. C.I.
LENDER'S NAME
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE REf�D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNV IS CORRECT.
I AGREE TO COMPLY WITH ALL CIN AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
CONSTRUCTION,AND HERERV AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTKNIED PROPERTY FOR INSPECTION PURPOSES.
PE E NAME. (PRINT)
S AT RE OF PERMITTEE DATE
WHITE-Department Copy,YELLOW-Finance Copy,PINK-ASSeuor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY� DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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OWNER-BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLL<WYING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY VMICH REW IRES.A PERMTTTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRKMi TO ITS ISSUAAK:E.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 UW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSK)NS CODE)OR THAT IRE OR SHE IS E%EMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TKNI.ANY VgLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(5500).):
^ 1.AS OWNER OF THE: PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATK)N,
WILL DO THE WORK,AND 1"HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7011, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE OW 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 N07INTENDED OR
OFFERED FOR SALE IF HOV�IEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TK7N,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THIS PROPERTY,AM E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7011, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT APP'LV TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS DCENSE UW.).
^ I AM E%EMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SEC7KNJ 7000)Of DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
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COMPENSATION,A:i PROVIDED BV SECTlON 3700 OF THE OBOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
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I CERTIFY THAT IN'DiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO SECOME SUBJECT TO THE
WORKERS'COMPENSATK)N OWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE V/ORKERS'COMPENSATK)N PROVISIONS OF SECTK)N 3700 OF THE LABOR
CODE,I SHALL FOFtTNWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECDRE WORKERS'COMPENSATION COVERAGE IS UNOWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TC/CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLURS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LIBOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE REAR THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT.
I AGREE TO COMPLY WITH,4LL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUII.DING PERMTT APPLICATION
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE: ANV CITY OR
COUNTY WHICH REQUIRES A PERMRTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TORE, PRIOR TO ITS ISSUIWCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED
STATEMENT THAT HE OR;.HE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE IAW(CHAPTER Y(CXHAMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSgNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TKNI.ANV VIOLATION OF Sf_CTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FWE HUNDRED DOLLARS(f500).):
^ 1,AB OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND'rHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS IX1DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS 01; IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWV EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
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TKkI,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPO:iE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7014, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS DCENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 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
0 (COMMENCING WITH SEC'TKNI 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOILCE AND EFFECT.
LICENSE CUSS_LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER F'ENALN OF PERJURY ONE OF THE FOLLOWING DECURATKJNS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOFI WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATKNJ INSURANCE,AS REQUIRED BV SECTION
37000E 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 NUMBER_
(THLS SECTION NEEC NOT BE OOMR.EfIDOFTI-IE PERMIT IS FOR ONE HUNDRED DOLLARS(f100)Oli LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SMALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SVBJECT TO THE
WORKERS'COMPE NSATKKV LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULO BECOME
SUBJECT TO THE WORKERS'COMPENSATKKV PROVISIONS OF SECTION 3700 Of THE TABOR
CODE,I SHALL FOFLTHWITH COMPLY WITH THOSE PROVISKNS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATKN COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f100,000j,IN ADDITION TO THE COST OF COMPENSATKON, DAMAGES AS PROVIDED FOR IN
SECTION 370f OF THE LABOR CODE.INTEREST AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER F'ENALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 HAVE REND THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
ADDRIESS o�,L� U�Gq I�.I•L�QC1�Id��(; � �YI� i"�V;
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNIDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRAC LI-
CENSELAWFORTHEFOLLOWINGREASON(SEC.703t.5 BUSINESSAND PROFESSK)NS CODE: CITY OR
COUNTY WHICH RECIUIRES APERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR RE ANVSTRUC-
TURE. PRIOR TO ITS ISSU/JVCE,ALSO RECK11RE5 THE APPLICANT FOR SUCH PER 0 FILE A SIGNED
STATEMENT THAT HE OR S'�HE IS LICENSED PURSUANT TO THE PROVISIONS 0 E CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTKNV 7000)OF DIVISION 3 THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE IS FOR THE ALLEGED EXEMP-
TKNI.ANY VIOLATKkI OF SECTION 7031.58Y ANY APPLICANT FORAP IT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS J.):
OI,AS OMMEROF THE: PROPERTY,OR MV EMPLOYEES WAGESAS THEIR SOLE COMPENSATION,
MAIL DO THE WORK,AND 1-HE STRUCTURE IS NOT INTE D OR OFFERED FOR SALE(SEC. 7041, BUSI-
NESS AND PROFESSIONS(X7DE:THE CONTRACTOR ENSE UW DOES NOT APPLY TO AN OWNER OF
PFOPERTY WHO BURRS OR IMPROVES THEREON D WHO DOES SUCH WORK HIMSELF OR HERSELF OR
TNHOUGH HIS OR HER OWIV EMPLOYEES, PR ED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
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IMPROVE FOR THE PURPO:iE OF 5
'^ I,AS OWNER OF THIE P RTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
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CENSE LAW DOES NOT AP TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FO C:H PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LA
^ I AM MPT UNDER SEC. B. 8 P.C. FOR THIS REASON
OWNER
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTKKJ 7000)Of DIVISION 3 OF THE BVSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOR
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DATE Y�� �d U CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
i HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 37W OF THE L<SOR CODE, FOR THE PERFORMANCE
OF THE WORK FOFI WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION IN
URANCE CARRIER AND POLICY NUMBER ARE:
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CARRIER���X�� ^��� �• *�
POLICY NUMBER_,�� �L�� � I,s�
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I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO HE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD OME
SUBJECT TO THE YVORKEfIS'COMPENSATION PROVI NS OF SECTI OOF T LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH THOS P IONS.
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SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5700,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CO
NS7$LICN�R'L'EFTDING AGENCY
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FOR THE PERFORMANCE OF THE WORK FOR WHICH THISPEWM ISSUED(SEC. 3097,CIV.C.).
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LENDER'S NAME��„�
�E IL�VOER'S ADDRESS
I CERTIFY THAT I HAVE RE/1D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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-MENTION D PROPEERTY FOR INSPECTK)N PURPOSES.
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117
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OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CIXJTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC.7031.6 BUSINESS AND PROFESSKNS CODE:ANV CI7V OR
COUNTY WHK%i REWIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRIOR TO ITS ISSUIWCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR :THE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER�((XMIMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TKN4.ANY VK)LATION OF SIECTION 7031.6 BV ANV APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT TO
A CML PENALTY OF NOT NK>RE THAN FIVE HUNDRED DOLLARS(f6oD).):
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70x4, BUSI-
NESS AND PROFESSIONS OODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SKE IF,HOINEVER 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).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PRO.IECi (SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
W/q CONTRACTS FOR SUQi PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (OOMMENCING WITH SECTK)N 7000)OF DIVISKXJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
AND EFFECT.
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I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATKI,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 I,IAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTK)N
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
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WORKERS'COMPENSATION IAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SU&IECT TO THE'JJORKERS'COMPENSATION PROVISK)NS OF SECTK)N 3700 OF THE LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISKNS.
DATE:APPLICANT:
WARNING: FAIWRE 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(f 100,000),IN AODI710N TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LAEK)R CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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. 3087,CIV.C.).
LENDER'S NAME
LENDERS 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 UWS RELATING TO BUILDING
CONSTRUCTK)N,AND HEREBY AUTHORRE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
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COUNTY WHI(�F gEOUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRKMi TO ITS FSSU/WCE,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 Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VK)I-ATgN OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ I,ASOWNEROF THE: PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIq SOLE COMPENSATK)N,
WILL DO THE WORK AND 1'HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7041, BUSI-
NESS AND PROFESSNNS(XJDE:THE CONTRACTORS LICENSE UW 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 OWIV EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOVYEVER THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE-
TKXV,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID N07 BUILD OR
IMPROVE FOR THE PURPO:iE OF SALE).
^ I,AS OWNER OF THIC PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCTTHE PRQIECT(SEC. 70{4, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APF'LV TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B.a P.C. FOR THIS REASON
DATE OWNER
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
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LENDER'S NAME
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMTT APPLICATI �, ��,�
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ADDR�SS�
CITY-�F' I 1 J �;ZIP� <A-TEL(
ARCH/ENG/_�^�,
DESIGNER
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OWNER-BUILDER DECLARATION
LICENSED CONTRACTORS DECLARATION
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QUANTITY I DESCRIPTION
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Valuation ADJ.AREA
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAT
CONSTRUCTlON LENDING AGENCY
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT OSELF-INSURE FOR WORKE
COMPENSATK)N,AS PROVIDED BY SECTION 37000E THE BOR CODE. FOR THE PERF
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �-
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENS ION INSUR CE CARRIER AND POLICY NUMBER ARE:
CARRIER�,1 � � �(-� ��t(�i �(�,7�_I,7��� ��jf�Z��
POLICY NUMBER
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THI PERMIT I$F!6$UED.I
SHALL NOT EMPLCY ANV PERSON IN ANY MANNER SO AS TO BECOME UBJECT 0 THE
WORKERS'COMPENSATKKV LAWS OF CALIFORNIA,AND AGREE THAT IF OULO B
SUBJECT TO THE VVORKERS'COMPENSATION PROVISIONS OF SECTION 3700 HE LABOR
CODE,I SHALL fOFRHWITH COMPLY WITH TI SE PROVISIONS:?
DATE: � ��> APPLICANN�/_!>'t_\i��%'-�{•'�-��
WARNING: FAIWRE 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(1100,000(,IN ADDITION TO THE COST OF COMPENSATKKJ,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
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.CJ.
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES,
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N0.
PRESS
FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COIvIIvIUNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS II-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANV 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 H (G�MMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT FIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TK)N.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES W ITH WAGES AS TNEIR SOLE COMPENSATION,
WILL W THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESSAND 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,HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE V EAR OF COMPLE-
TION,THE OWNER-BUILDEF:WILL HAVE THE BURDEN OF PROVING TIlAT HE Oq SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,AS 0 WNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC�
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PE:NALN 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
MV LICENSE IS IN FULL FORCE AND EFFECT.
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WORKERS'COMPENSATION D LARATION
I HEREBY AFFIRM UNDER PF:NALN OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 37000E 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 BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORK
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I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY'ANV 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 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FOR-fHWITH COMPLY WITH THOSE PROVISIONS.
DATE: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(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABO R CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
1 HEREBY AFFIRM UNDER Pf:NALN OF PERJURY THATTHERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE 01=THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
1 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,ANO HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MFjJTiONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE N)I '(
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SIGNATUR 0 ERMITTEE GATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
EXPIRED
MAY 0 9 2003
PRESS
FIRMLY
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117
BUII.DING PERMIT APPLICATION
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLINVING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REWIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRKNi TO ITS ISSU/JVCE,ALSO REWIRES 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 B (COMMENCING WITH SECTKNI 7000)OF DIVISK7N 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 VKKATKXV OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF THF: PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND 1-HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.Todd, BUSI-
NESS AND PFIOFESSK)NS(XX)E:THE CONTRACTORS LICENSE UW 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 OWIV EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOYVEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TKXV,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPO:iE OF SALE).
^ I,AS OWNER OF THIS PFIOPEATY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70U,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 FDR SUCK PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS ucENSE uw.).
^ I AM EXEMPT UNDER SEC. i B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTKKV 7000)OF DIVISION 3 OF THE BUSINESS AND PROF't5510N5 CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
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WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER F'ENALN OF PERJIIRV(NJE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT 70SELF-INSURE FOR WORKERS'
COMPENSATON,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORN FOFt WHICH THIS PERMIT IS ISSUED.
.�I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOIR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY
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f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FGR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANIY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE VVORKERS'COMPENSATION P dVISIONS OF SE 10 13700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH TH PRO\(�6
DATE: � �I-Ae!�APPLICANT: L
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(5100,000),IN ADIJITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LABOR CODE,INTEREST,AND AT i ORNEY'S FEES.
CONSTRUCTlON 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.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 HAVE REI\D THIS APPLICATION AND STATE THAT THE ASOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTICMI,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTK)NED PROPERTY FOR INSPECTK)N PURPOSES.
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WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
EXPIRED
MAY 0 91003 PRESS
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I HEREBY AFFIRM UNIDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE(X)NTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7037.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHK7( REQUIRES A PERMRTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIRANY STRUC-
TURE,PRKNi TO ITS ISSU/JdCE.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-
CENSELAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSKNIS COOED OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TK)N.ANY VIOLATKNd OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CINL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
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WILL DO THE WORK,AND 1'HE STRUCTURE IS N07 INTENDED OR OFFERED FOR SALE(SEC. 706, BUSI-
NESS ANO PROFESSIONS (X)DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUSDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWIJ 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 PURPO:iE OF SALE).
0 1,AS OWNER OF THIS PROPERTY AM EXCI.USNELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WFp CONTRACTS FOR SUC H PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS IICENSE LAW.).
0 I AM EXEMPT UNDER SEC. B.8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
P(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,ANO
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WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECURATK)NS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSLIRE FOR WORKERS'
COMPENSATKN,AS PROVIDED BY SECTION 3700 0=THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOE',WHICH THtS PERMIT IS ISSUED.
�I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOVIRED RY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKExxRv COMPENSATKOi INS^^URCCAN„C"E CARRI�ER�AJND POLICY/N'UMBER ARE:
CARHIER
y��,7���_�4.��y�I� 1 I � �OF'.
POLICY NUMBER_
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1
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(THIS SECigN!vcEO
NOT
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BE
1 CFATIFY THAT IN'THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY AN7 PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKN LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE VYORKERS'COMPENSATION PR VISK>NS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FO:ITHWITH COMPLY WITH THO PROV I
r
DATE: i-�-�"�II APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'C MPENSATION COVERAGE IS UNLAWFUL,ANO SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER F'ENALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSVED(SEC. 3097,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPI.RN FOR INSPECTION PURPOSES.
t�/�
PERMITTEE NAME 4PRINT)
i
SIGNATUR F RMITT 1. � DATE
f
WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
-4?1.
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CITI'OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
2182� E.Copley Drive
(909)860-3195 Fax(909)861-3117
BLTIILDING PERMIT APPLICATION
WNITE-Department Copy,YELLOW-Finance Copy, PIN
EXPIRED
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PRESS
FIRMLY
ULIJIII�U
CITY OF DIAMOND BAR
DEPARTMENT OF CONIIvIUNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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CITY OF DIAMOND BAR
DEPARTMENT OF CONA�IUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 6
BUILDING PERMIT APPLICATII�N tl�'t
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ADDRESS.
APN L.OT TACT
OWNER
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APPLICANT TEL.
CONTRACTOR�^
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER�'
ADDRESS
CITY ZIP 2TEL.
OWNER-BUILDER DECLARATION 1
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLC W ING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV 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 a (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSK)NSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV 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(f 500).):
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH 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 GODE: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
THRIXIGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS APE NOT INTENDED OR
OFFERED FOR SALE. IF,HOW EVER,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 FOq THE PURPOSE OF SALE).
^ 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
�I AM EXEMPT UNDEFI SEC. B. 8 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
B(COMMENCING WITH SECTK)N 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
LL
LICENSE CLASS
� LIC. N0.
I
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DATE 1 " � �� ?�•�CONTRACTOR CAr�,A'I,�G\•�L��
V
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 SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR'NHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY W
RK
0
ERS'COMPENSA
T
ION INSURANCE CARRIER AND POLICY NUMBER ARE:
Cc
t
I
fY
CARRIER K-
� �� L-
POLICY NUMBER i'�I ��W�S7G.
(THIS SECTXXV NEm NOT BE OOMPLETED OF THE PEFIMFT IS FOR ONE HUNDRED DCLLAAS(5700)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANV 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 PROV ISIONS OF SECTlON 3700 OF THE LABOR
CODE.I
HALL FORI-HWITH COMPLY WI THOSE PROVISIONS.
S
DAT
--�'I
Lt-
fCi
APPLICANT:
E:
WARNING: FAILURE TO SECIIRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37090E 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 A_L CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREI3V AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE
ABOVE-MENT
I
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FOR INSPECTIO
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P
URPOSES.
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PERMITfEETIAlAE(PRINT)
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SIGNATUREO PERMITTEE fff DA
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WHITE-Department Copy,YELLOW-Finance Copy, PIN
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910-01 oXr w- 1tA$9.crronl mOLy'
CITY OF DIAMOND BAR
S
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
EXPIRED
MAY 0 9„2(103
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JOBSITE
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CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/G^
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DESIGNER•7�
�'CJ-.
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRK)R 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-
FESSIONSCODE)ORTHAT HE ORSHE IS E%EMPT THEREFROM ANO THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BV ANY APPLICANT fOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 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. 7064,BUSI-
NESSAND PROFESSIONS CEDE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OFI 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,HOMIEVER,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).
^ I,AS OWNER OF THE_PROPERTY,AM EXCLUSIVELY CONTRACTlNG W ITH 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 BU ILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTORIS)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
CJ I AM EXEMPT UNDER SEC. B. 8 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 FOF'�CE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,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 M,4INTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE OOMPLLTED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($1 W)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 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE VIORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FOFTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: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(f 100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 37080E THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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,CI V.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 HAVE REP.D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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 PROPE:RN FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEF DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy