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CITY OF DIAMOND BAIT
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
w 21660 E. Copley Drive Suite `190`
(909)860-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APKWATONFIRMLY
14
JOBSITE A {
ADDRESS
APN _ LOT 0— TRACT S-1)
OWNER '
ADDRESS
CITY /i,7 /fie ZIP(: i -9X TEL.�.�e�L-.:�L"—L#r
APPLICANT; ! i/ TEL
CONTRACTOR QA'-,
ADDRESS ;:kir A.L'
CITY 4JVJd .,&-2 ZIPTEL. `
ARCR/ENG/
DESIGNER &A G1�+�1
ADDRESS 2 �> �1�;a�'�1_
CITY �njz-@'a'#iad_- /ZIP '�I— NTELA
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH RECUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRAWSTRUC-
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 B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BU§NESS'AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION. ANY
VIOLATK)N OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 7O
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($5W).): -
D 1, AS OWNER OFTHE 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. 7114 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 CR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMOLE'
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT RUILD 'OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS GODS: THE CONTRACTORS U�
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) _CFNSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.).
711 AM EXEMPT LINDER SEC- `_ B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORSDECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION 7000) OF DIVISION $ OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL. FORCE AND EFFECT.
LICENSE CLASS I V72 LIC. NO, 1rte'", J
DATE F ,d! �. CONTRACTOR �A)1 LSI/-Y6� '
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 BY SECTION '37000F THE LASOR-CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REGUiRFD. RY 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 i % z,, �? A. —�, •
POLICY NUMBER
()HIS SECTION NEED NOT BE OOMWI.ETEDOFTHE PE14TISPORONEHUNDIREDDOILLAM ISI00)ORLESS).
I CERTIFY THATIN 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 THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LIBOR
CODE, I SHALL FORTHWITH COMPLY WITH TH PROV SI(AS,
DATE (
' � «APPLICANT.
-� ' FI
H
WARNING: FAIIUIETO SECURE WORKERS'COMPENSATION COVERAGE ISDN WFTbL,A SHALLRE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE H 06RED HOUSAND
DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OFTHE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
i CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I$ ISSUED (SEC, 3007, CIV. C.).
LENDER'S NAME__
LENDER'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICA71ON 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 HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTYTO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
i
I PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
.. -
APPLICATION /L' � p�
DATE / Y I�J �Q
PER
UMBER .. ,: P!C
NUMBER/;I-7
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ISSUE
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