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CITY OF DIAMOND BAR
DEPARTME'VT OF COIvINIUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE II�
ADDRESS_
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APN 0'T T CT-
OWNER� .i+�r,�
ADDRESS�t!�'6
CI�-c ZIP�/� 7ELCf��•��-3
APPLI ANT TE
CONTRACTOR
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CI-���_ZIp��-yy^'TEL./
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
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 PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REOUIRESA 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-
CENSELAW(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.ANV VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJEC fS'f HF APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500(): -
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W iTH WAGES AS 1 HEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS N07 INTENDED OR OFFERED FOH SALE(SEC. 7044, BUSI�
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES N0� APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORN 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 'HAT HE OR SHE DID NOT BUILD OH
IMPROVE FOR THE PURPOSE OF SALE).
C I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCTTHE PROJECT(SEC. 70a<, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI�
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY W HO aUI1.DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE 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 PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSiONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
//�7
LICENSE CLASS_�_��_LIC. N0.f9'Z�/
DATE ' '-�� ���CONTRACTO I
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF�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 MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E 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 NEm NOT BE OOMPLETED OF THE PERMfT IS FOR ONE Id1NDRED DOLLARS(f100)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 SUBJEf,T TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT I I SHO LD BEC ME
SUBJECT TO THE WORKERS'COMPENSATION OVISIONS OF SECT 370 F THE BOR
CODE.I SHALL FORTHWITH COMPLY WITH EP OVISIONS.
T
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DA
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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 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PEN ALN 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.I.
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(:IN AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPE TION PURPOSES.
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G TORE OF ERMITTEE DATE
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