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CITY OF DIAMOND BAR � ��'�Jj� l l�I—�'
DEPARTMENT OF COMMUNi'ffY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3 L95 Fax(909)861-3117 PRESS
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� I CERTIFV THAT I MAVE REA�THIS AFPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
W I AGREE TD CAMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING
� CANSTRUCTION,AND HEREBV AUTFIORIZE REPRESENTATIVES OF THIS COUNTY TO ENiER UPON THE
� ABOVE-MENTIONE�PROPERTV FOR INSPECTION PURPOSES. �
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CITY OF DIAMOND BAR �• ��CJI 1 ���I�
DEPARTMENT OF COMMUNifY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
PRESS
(909)860.3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION FIRMLY
ADDRESS L �--��y����C pr�c--��
APN LOT 6 TRACT 2
OWNERII_Z�-�-/4L�+
ADDRESS'C/L"'r V
CITY,/�I/�"-Y(f7�i'��. ZIP�TEL6� � 1-�s
APPLICANT[�q-� �/�/-�rJA�Y�TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE:ANV CITY OR
COUNTY WHICH REW IRES 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 B (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TK)N.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL 00 THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC. 7ou, BUSI-
NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES N07 APPLY 70 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,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLDWITHIN ONE VEAROF 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 CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70u, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES N07 APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTKNJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS
LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWING DECLARATKNJS:
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 FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTKNJ
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 NDT BE DONPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS(5100)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 SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKN LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT 70 THE WORKERS'COMPENSATION PROVISKNIS OF SECTION 3700 OF THE LIBOR
CODE. 1 SHALL FORTHWITH 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(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
1 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
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNI IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FORINSPECTKIN PURPOSES. '
opy,YELLOW�inance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy