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I7EPARTMBNT OF COMMUNITY&DEVELOPMBN'T SERVICES
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
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APP�ICANT
CA AI CONTRACTOR�9-4.G
ADDRESS a"f P'
CITY ZIP TE�.
ARCH/ENG/
DESIGNER c,
ADDR SS
CIIY ZIR�J �-7TEL
OWNER-BUI�DER DEC�ARATION St�BATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE t_AW FOR THE FO��OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REWIRES A PERMIl�fO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANY STRUC.
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE IAW(CHAPTER 0(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 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS($500).):
^ I,AS OWNER OF THE PROPERTY.OR MY EMP�OYEES 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�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS 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 SO�D WITHIN ONE YEAROF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS 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 OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERIURY 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 FU�L FORCE AND FFECT.
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LIC. NO.
LICENSE C�P,SS
{/
DATE :n0-i
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY ONE OF THE FO�LOWING DECLARATIONS:
I
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE. FOR THE PERFORMANCE
/JF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
3700 OF THE IJ�BOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' MPENSATION INSURANCE CARRIER AND PO�ICY NUMBER E.
CARRIER
POLICY NUMBER
F THE
T IS FOR
E HUNDRED DOL
100
OR LESS
M
ARS
Ff
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PER
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ON
L
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1.45 eec
NNEEQNOTB O
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 3 00 OF THE�ABOR
CODE,I SHAL�FORTHWITH COMP�Y WITH TH PROVISIONS.
Gr rr 7rA
S
/D•/
APPLICANT.
DATE:
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�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 I.ABOR CODE. INTEREST,AND Al�'ORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
HIIC THI ERMIT IS ISSUE(SEC. 3097,CIV C.).
FOR THE PERFORMANCE OF THE WORK FOR W
f
LENDER'S NAME
LENDER'S ADDRESS
I 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 INSPECTION PURPOSES.
PERMITI'E AME(PRINT)
2 SIGNA!! OF PERMITfEE DATE
APP�ICATION ZZ 1-r PERMIT�)P/Cc(-Z�L
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