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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
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BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 21 b IS Dewe(_ yr
APN LOT TRACT S2
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DESIGNER ,
DESIGNER
ADDRESS
CITY ZIP TE
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERAIRY THAT 1 AM EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FOR THE FOLLOWINGSEASON (SEC.7031.5 BUSNESSAND PROFESSIONS CODE ANY CRY OR
COURT WHICH REQUIRES APERMR TO CONSTRUCT. ALTER, NPROVEDEMOUSIE OR REPAIR ANY 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 3 (COMMENCING WITH SECTION 70DO) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE 15 ED(CMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7001.6 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (9500)-I.
O LAS OWN ER OF THE 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. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY YW10 BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OAR/ EMPLOYEES. PROVIDED THAT SUC H IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORF. SNIF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOAPLE-
TION, THE OYME94KAWER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O I, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PIIOUECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI.
ES NOT
CENSE LAW DOAPPLYTORN OWRNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHOCONTRACTS FOR SUCH PROJECTS WITH CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.I,
O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER _
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PER)URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
e (COLMENCNO WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FOR D EFFECT.
LICENSE S_ LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
-1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF.INSVRC FOR WORKERS'
COMPENSATION. AS PROVDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKEPS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MYW(�!R�� ERS'COMPSATDN INSURANCE CARRIER AND POLICY NUMBER ARE:
CMRUERyd -
POLICY NUMBER, I_ x
rw SECTION NEEDD NOT BE COMI LETED OFTHE PERMTIS FORONE HE.FLIISD DOLLARS (SIM, OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKEFW COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT P I SH OLLD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS PROVISIONS OFS 'TIO 77 OF OROF OR
1 FORTNYATH COMPLY WITH THOSE PR �KXd
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DATE: _ APPLICANT:
1
WARNING. FAILURE TO SECURE V.OHKERS'COMPENSATKNI COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (3100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3701 OF THE LABOR CODE. INTEREST AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
i
1HEREBY ERFO tNDER PENALTY OFK FOR YTHAT IS PE ISACONSTRUCTION LENDING AGENCY
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FOR THE PERFORMANCE OUTHE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097. CII G).
I Tr
LENDERS NAME
LENDER'SADDAESS
I 1 CERTIFY THAT I HAVE REM THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO OOMPLY WRH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON
TIONTME
ABDDO__VE-MENTIONEDP ERTY FORT NSPECTgN PURPOSES.
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� PERMITTEE E HT)E ( I
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� SIGNATURE OF DEPy rE
PRESS
FIRMLY
APPLICATIONl' (r �j PERMIT i� P/C
DATE ` i 1 NUMBE R
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE Ley CR::tCP
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Ito
GaragelCarport
WPatio/Dock
LL_
Pool/Spa
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Valuation sw ADJ.AREA
QUANTITY DESCRIPTION FEE
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NOV 1.9 1999
CITY OF DIAMOND BAR
CONSTRUCTION
BUILD ANI) AFET Y
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMTP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
RECPT. NO. D 41 PAID BY I Lo ALIDATION
WHITE—Depanment Copy, YELLOW—finance Copy. PINK—Assessor Copy, GOLDENROD --File Copy, GREEN --Applicant's Copy
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