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CITY OF DIAMOND BAR
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21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
'�'%��Y� BUILDING PERMIT APPLICATION FI LY
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APN LOT TR CT DATE � CONST. GROUP
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p 1 HEREBY AFFIRM UNDER PENALTV OF PERJURV THA71 AM E%EMP7 FROM 7HE CONTFAC70R5 LI- G8f29B/CBfPOIi
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w 7URE.PRIOR TO ITS ISSUANCE,ALSO REaUIRES TNE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w
STA7EMENT THA7 HE OR SHE IS LICENSED PURSUAN7 TO THE PHOVISIONS OF THE CONTRACTORS LI�
� CENSE lAW(CHAPTER B(COMMENCING WITH SECTION)000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
FESSIONS CADE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP� (�
� TION.ANVVIOLATIONOFSECTION7031.5BYANVAPPLICANTFORAPERMITSU&lECTSTHEAPPLICANTTO Z Re-Roof ��y.
� A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(SSao�.):
0 ❑I,ASOWNEROFTHEPROPERiY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COrt1rtI0fC18I �
Z WILL DO THE WORK,AND THE STRUCiURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704a,BUSI� J
� NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED 7HAT SUCH IMPROVEMENTS ARE NO71N7ENDED OR m
Q OFFEREDFORSALE.IF,HOWEVEF�TiEBUILDINGOFIMPROVEMEN7ISSOLDWI7HINONEYEAROFCOMPLE-
Z 710N,7HE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w ❑I,ASOWNEROFTHEPROPERTV,AME%CLUSIVELYCAN7RACTINGWITHLICENSEDCANTRACTORS
� 70 CONS7RUCT THE PR0.1EC7(SEC.70a4,BUSINESS AND PROFESSIONS CODE:THE CONTRAC70R5 LI� V81UellOn ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANON?JEROFAPROPEFTYWHOBUILDSORIMPROVESTHEREON,AND
� WHOCANTRACTSFORSUCHPR0.IECTSWI7HACON7qAC70R(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTI DESCRIPTION FEE �
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� ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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DATE OWNER U I
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT 1 AM LICENSED UNDER PROVISIONS OF CHA7TER �
d 6(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PROFESSIONS CODE,AND z
X MV LICENSE IS IN FULL FORCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBVAFFIRM UNDER PENALTV OF PERJURV ONE OFTHE FOLLOWING DECLARATIONS: Z
� _IMAVEANDWILLMAINTAINACERTIFICA7EOFCANSEN7TOSELF-INSUREFORWORKERS' _
Q CAMPENSATION,AS PFiOVIDED BY SECTION 3700 OF THE LABO(i CODE,FOR THE FERFORMANCE W
OF7HE WORN FOR WHICH THIS PEHMI7IS ISSUED. �
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w I HAVE AND WILL MAMTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION (��y^ I
Q 37000F THE LABOR CODE,FOR TFiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS X � � '
ISSUED.MV WORKERS'COMPENSATION INSUFiANCE CARRIER AND POIICY NUMBER APE: CONSTRUCTION U [�
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� .CARRIER PLAN REVIEW
� POLICYNUMBER ELECTRIC
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� (iHISSECTIONNE�NO7BEOJN�PLEfE�OFTHEPERA4TISFORONEHUPDREDDOLLNiS(5100)ORLESS). PLUMBING
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WOHK FOR WHICH 7NI5 PERMIT IS ISSUED.I MECHANICAL
�} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
N WORKERS'COMPENSATIONUWSOFCAUFOHNIA,ANDAGREETHATIFISHOULDBECAME INSPECTIONFEE
= SUBJECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SEC710N 370o OF THE LABOR
CADE.I SHALL FORTHWITH COMPLY W17H THOSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT. ,�
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENEAGY P/C
� SUBJECTANEMPLOVER70CRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOF IN
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
pw_ CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3087,CIV.C.�. .
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� LENOER'S NAME
H LENDER'SADDRESS
� TOTAL FEES ��
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE WFORMATION IS CARRECT.
� I AGREE TO CAMPLV WITH ALL pTY AND COUN7V ORDINANCES AND STATE UWS RELATING TO BUILDING �
� CANSTRUCTION,AND HEREBV AUTHORI2E REGRESENTATNES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE-MENTIONED 7ROPERTV FOR INSPECTION PURPOSES. COMMENTS
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� SIGNA REOFPERMITTEE DATE
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ROOF SHEATHiNG ��I �/(i� � _ l � 8 FT. B�ND BEAi� � '
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FRAMIPJGNENTILIATION � i ; FINAL BOfVD BEAP�I ;
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ROOF COVER � PRE-GRADING i __ ' _
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ROUGH PLUMBING _ __ ' FINISH GRADiNG --- --_-__� �----_-_------
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CEILING IIV�ULATIOIV � OFF SITE IMPS. j
DRYWALL NAILItVG DEDICATIONS
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