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DEPARTMENT OF COMMLINITY&DEVELOPMENT SERVICES
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21825 E.Copiey Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
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ADDR SS
APN LOT ItNj TRACT S �� ��Cr's 7
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ADDRESS SQs I C)(� l�Q C494-ES r C r-
CITY r G4)il ZIP 1 i-76 TEL.�t 1 3't(e C'g L
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CITY IL'A-L+ NA/k_ZIP 41:7 TEL.24/'d10
OWNER-BUI�DER DECLARATION
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I HEREBY RFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE(AW FOR THE FOL�OWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMITi'0 CONSTRUCT,A�TER,IMPROVE, DEMOLISH,OR REPAIRANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,A�SO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FI�E A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE t_AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BV ANT APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS($500).):
^ I,AS OWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUII.DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSE�F 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 SO�D W ITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPRO E FOR THE PURPOSE OF SALE).
I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE IAW DOES NOT APPI-Y TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE�AW.).
^ I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OZ-OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PEiL1URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICENSE CLASS�IC. NO.
DATECONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURP,NCE,AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOL�ARS($100)OR�ESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB)ECT 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 LABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
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WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHA�L BE
SUBJECT AN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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