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CITY OF DIAMOND BAR !�`
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
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JOBSITE,���
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OWNER���"IrfitTGl-C'-�^�C°C�JJJ�J�J
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CITYL-/xs/17VC't�i.�e ZIP�T Uv711"j
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�AW FOR THE FOL�OW LNG REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
CWNTY WHICH REOUIRESAPERMITfO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUG
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-
CENSELAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSK)NS CODE)OR THAI'HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE AL�EGED EXEMP-
TKNI.ANY VIOLATKXI OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENA�TY OF NOT IAORE THAN FIVE HUNDRED DOLtARS(f500).}:
^I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES ASTHE�R SO�E COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7046, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OVM EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR BALE IF, HO WEVER THE BUILDING Oq IMPROVEMENT IS SO�D WITHIN ONE YEAR OF COMP�E-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041,BUSINESS AND PROFESSIONS CODE:THE CONTRP,CTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO OONTRACTS FOR SUr,H PRO]ECTS WITH A CONTRACTOR(S)�ICENSED PURSUANT TO THE CONTRAG
TORS I.ICENSE UW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
t-ICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COMMENCING WITH SECTKNd 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FUL�FC RCE AND EFFECT.
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LICENSE CLA S
LIC. NO.
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7.
DATE�/3�-�.���)CONTRACTOR_L+�-r�f�LSy�%C.'��_
NfORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARA,TIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SEI.F-INSURE FOR WORKERS'
COMPENSATON,/1S PROVIDED BV SECTION 3700 OF THE�P,BOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE L
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COD
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E
,F
OR T
HE PERFORMANCE OF THE WORK FOR WHIGH THIS PERMIT IS
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CARRIER Y WV�?U JV,l/A�INSURANCE CARRIEGp� PO�ICY NUMB�;ARE:
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POLICY NUMBER/� �'7 N�)
(THIS SECTION NEED NOT BE COMPLETED OF THE PEW.tIT IS FOR ONE HUNDRED OOU.AFiS(f100)OR�ESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBIECT TO THE
WORKERS'COMPI=NSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE'NORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMP�Y WITH THOSE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRMIINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOL�P,RS(f 100,000),IN AC DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTK)N 3]08 OF THE�ABOR CODE,INTEREST,AND AITORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMAN
E OF TH
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FOR WH
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PERMIT IS ISSUED(SEC. 3097,CI V. C.),
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LENDER'S NAME J
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LENDER'
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DDRESS
I CERTIFY THAT I HAVE RE 4D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS REIJaTING TO BUILDING
CONSTRUCTION,AND HEFIEBV AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTK)NED PROPERTY FORINSPECTKNI PURPOSES.
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PERMIITEE NAME(PR T)
SIGNATURE OF PE I'("f DATE
WHITE-Department Copy.YE�LOW--Finance Copy, PIN
PRESS
FIRM�Y
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CITY OF DIAMOND BAR
INSPECTION RECORD
DATE�INSP��'R���tNSPECTI4N DATE
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