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^ �� CITY OF DIAMOND BAR •
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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U1,1�IIIJU Ii�1R I
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMTT APPLICATION
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APN 7y'��I_OT�D TRACT�8D
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CITY 17ifirn.n .at'ZIP TEL./-3/�/
APPLICANT�g� �r ti �'TEL. S'70'a'�'72
CONTRACTOR IMAM') LT�-C-L
ADDRESS���S'L YL'Y'1'i�A
CITY�I�Kb ZIP t71 D TEL. 2.S
ARCH/ENG/
DESIGNER�1'1 C.a"t•Gln�.r
ADDRESS IZO I�y-� 1 � �„
CITY�4naL�ei�_ZIP 9'La47fELJf�tf-630-�(
OWNER-BUILDER DECLARATION
I HEREBY AFFRM LINGER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE: ANV CITY OR
COUNTY WHICH REOI11RE5 A PERMIT TO 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 (IbMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)ORTHA7 HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VNN.ATKNJ OF SECTION 7031.5 BV ANY APPLICANT FOR A 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 DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7014, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO 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
OFFERW FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TKHJ,THE OWNER�BUILDF:R WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF TFIE PROPEHIY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 701„ 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 A CONTRACTOR(S)LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE UW.).
^I AM EXEMPT UNDER SEC.e.a P.C. FOR THIS REASON
DATE_OWNER_
I-ICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEFUURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SE�TION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
CE AND
F
FECT.
MY LICENSE IS IN FULL FO
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DATE.64 0�-CONTFIACTOR�'a.rntnd
WORKERS'COMPENSATION DECLARATION
I HEREQYAFFIRM UNDER PENALTY Of PERJURY ONE OF THE FOLLOWING DECLARATIONS:
/
I HAVE AND WILL MAINTAIN A CERTIFICATE OF COIJSENT TO SELF-INSURE FUR WORKERS'
V
COMPENSATION,AS PROVIDED SV SECTION 3700 OF THE LIBOR CODE, FOR THE PERFORMANCE
�OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
RIER AND POLICY NUMBER ARE:
KERS'COMPENSATION INSURANCE CI
ISSUED. MY
WOR
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CARRIER�./0.� � L� "1' RT
POLICY NUMBER�y L� �3
(RiLS SECTION NEED NOT BE CflLPI. EfEDOF THE PEG MfT LS FOR ONE HUFDI7ED DOI.LAFIS(EtOD)OR LE55).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT 70 THE
WORKERS'COMPENSATION LAWS OF CALIFORNI AND AGREE THAT IF I SHOULD BECOME
SUBJ CT TO THE WORKERS'COMPENSA7KNJ PR ISIONS SECTK)N 3 00 OF THE LABOR
COD I SH FORTHWITH COMPLY WITH THOS PROV SK)N
�� APPLICANT�r
DATE:
II WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOVER'f0 CRIMINAL PENALTIES ANO CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(1100,000),IN ADDITION TO THE COST OF COMPENSATON, DAMAGES AS PROVIDED FOR IN
I SECTION 3708 OF THE LIBOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
I 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.).
I
LENDER'S NAME
LENDER'S ADDRESS
I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT.
I AGREE TO PLY WIT4 ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
�CONSTRUCTI,AND HEREBY AUTHOR2E REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MEN ED PROP OR IftISPECTKJN PURPOSES.
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WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy