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-��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES /^ .�.-. )C�` �
,� 21660 E.Copley Drive Suite 190 �''
(909)86Q3195 Fa�c(909)861-3117 �/�I PRESS
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o� JOBSITE � DATE CATION �— )�(, D\� NUMBER `.�"`1 Q'�" #/C
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y WORKERS'COMRENSATION LAWS 4F CALIFORNIA,ANDAGREE THAT IF I SHOlILO BECOME
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CAO ISHALLFOHTHWII'H(:OMV�VWITNTH EPROVISIONS. ISSUANCE
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J WARNING FAILl1RC TO 5[CURE WORKEPS'COMPENSATION CAVEfiAGE IS UNUWFUL,AND SMALL BE ENERGY P/C ... .
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� DOLURS(f1o0.000),INAOOITIdJT�THECOSTOFCOMPENSATION,DAMAGESASPROVI�EDFORIN ENERGYPEFiMIT
� SECTION 3]OB OF THE LABOR CODE,INTEREST AND ATTORNEV'S FEES. RETENTION FEE:
w CONSTRUGTION LENDING AGENCY PRE-ALT FEE:
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CL I HEREBY AFFIRM UNDEfl GENALTY OF PERJURV THAT THERE IS A CONSTRUCTIDN 1EN01NG AGENGV
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W1 CERTIFV TMAT I HAVE PEAO THIS AFPLiCATION AND STATE THATTHE ABOVE INFORMnT10N IS CORRECT. TOTAL FE ES � �(I -V�
� I AGREETO CAMPLV WITHlLLLCITV AND CAUNTY ORDINANCESANO S�ATE UWS REUTINGTO BUILDING
CONSTPUCTION,RND HE��.RE9Y AUTHORIZE REPRESENTATIYES OF THIS COUNTY TO ENTER UPON THE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMRTO CONSTRUCT,ALTER.IMPROVE, DEMOLISH,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 LI-
CENSE LAW(CHAPTER Y(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 ALLEGED EXEMP.
TON.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
C I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANTTOTHE CONTRAC.
TORS LICENSE LAW.).
0 1 AM EXEMPT UNDER SEC. B.A PC. FOR THIS REASON
DATE_OWNER
LICENSED CONTRACTORS DECLARATION
(HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE/WD EFFECT.
LICENSE CLASS
DATE CONTRACTOR_Aj 1-40#1
WORKERS'COMPENSATION DECLARATION
YAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
EREEB
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$ LKI HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
PENSATION.AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
THE WORK FOR WHICH THIS PERMIT IS ISSUED.
7 1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WOFI!(ERS'E:OMPEIISATION INSURANCE CARRIER AN9,POLICY NyIJBER ARE.
(TM ECTIOINN NEED NOT BE(X3 LETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
-' FE
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON .N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTlON 3700 OF THE LABOR
C00 I SSHHALL FORTHWITH COMPLY WITH TH E PRROVISIONS.
CATE. � APPLICANT:_/T--"
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($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 370$OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHI94 THIS, ERMIT IS ISS D(SEC. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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TRACT�S Z26 7
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR I ISPECTION PURPOSES.
PERMITIEE NAME(Po n
LIC. N0. 77571:5
PRESS
FIRMLY
APPLICATION Q PERMIT,Q(P/C
DATE NUMBER #
ISSUE TYPE OCC
DATE CONST. GROUP
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