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CITY OF DIAMOND BAR I IPWD
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 -A'--"-
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APPLICANT re •. ye l=r3�+;c
CONTRACTOR
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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. 703/.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNT( 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 U.
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3OFTHE BUSINESS AND PRO-
FESSIONS CODE) ORTHATHE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
710N. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANTTO
ACI ENAL7Y OF NOT MORE THAN FIVE HUNDRED DOLLARS(SSWP:
AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG. 7044. 8USI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUS.DSOR 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 GR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORI,S) LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
❑ IAM EXEMPT UNDER SEC. __ _B. S PC. FOR THIS REASON
DATE y J /,r
LICENSED CONTRACTORS D CC�TION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTKON 7000) OF DIVISION 3 OFTHE SUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS --_ LIC. NO.
DATE CONTRACTOR,_ _—._—___
I
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATION S:
1 _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FORWORKERS'
COMPENSATION, AS PROVIDED SY SECTION 37000FTHE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
LU _I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS RCOUIRED BY SECTION
3700 OF THE LARCR CLUE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER— — —.--
POLICYNUMBER
0
"BECTON NEED NOT BE COMPLETED OFTHE PERI 6 FOR ONE HUNDRED Wd.IARS(3100) ORLESS),
W I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TFJS PERMIT IS ISSUED, I
Z
CIS SHALL NOT EMPLOY ANY PERSON W ANY MANNER SO AS 70 BECOME SUBJECT TO THE
n WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS,
DATE: APPLICANT:
J WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (S100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
J SECTION 37030F THE LABOR CODE. INTEREST AND ATTORNEYS FEES.
J CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC.3097, CIV. C.).
J
_ LENDER'S NAME -_
LENDER'SADORESS _
I CERTIFYTHAT (HAVE READ THIS APPLICATION AND STATE THAT THEABOVE 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.
� PERMI (PR �
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OCT 0 3 2000 PRESS
FIRMLY
APPLICATIO PERMIT
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ISSUE TYPE OCC
DATE'— CONST, GROUP
ZONING SETBACKS
RW ❑
REAR ❑
LlFRONT
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL, NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
Garage/Carport
0
W
Patio/Deck 2 P,
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Commercial
Valuation = ADJ.AREA
QUANTITY
DESCRIPTION FEE
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ENERGY PIC`
ENERGY PERMIT
RETENTION F140 -l'
PRE -ALT FEE:
TOTAL FEES 30, w
COMMENTS
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RECPT. NO. _ .. PRID 8Y-VRLIDATIO
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—# -Ra Copy, iriKLEN—Applicant's L:opy
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