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CITY OF DIAMOND BAR
�� DEPARTMEN'I`t)F CnI�+IIviLINi`I`Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Faat(909)861-3117 �R�Ss
"-w� BUILDING PERMIT APPLICATIUN F.�IRMLY
a� JOBSITE � 1 �� 'i \ _ � dAPEICATIQN �� r�`.J PltJMBER_��_.• '-�`''#Jt �
ADdRESS_ 1 u' ���_
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.�,�— CENSE LAW(S:HAPTEfl 9((:OMMENGNG WITM SEC7IIXJ]p00)OF DIVISION 3 OF THE 6USINESS ANP PRO� PQOUSpB
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� TION.ANYVIOIATIqNOFSECTION703t,S8YANYAPPUCAN7iORA�ERMiTSUBJECTSTHEAPPLtCAMiO Z Re-Roof
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� CAMPENSATION,AS FROVIDEO BY SECTION 3700 OF THE 1A80R CODE,FOR fHE PEflFOflMANCE U ,,,,,, ,__„
OF TNE WbRK FCill WHICH THIS PERMIT ISISSl1Ed. W
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� 370Q OF TNE tA84R CODE,iOR THE PEftFOftMANCE OF Tlif wORK FGft WFNCH T4i45 PEflM1Tl5
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Z I CERTIFY THAT IN THE PERFORMANCE OF TNE WORK FOiI WHICH TNIS PERMIT IS I55VEU.I MECHANICA(. _^_ y—_
(;} SHA4LN07 EMPLOv ANV PEFSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE m ��-' '�
{jJ W6Fi%ERS'COMP=NSATION LAWS OF CAtiF4RFt4A,AND AGFEE i HAT IF i SHQtitD flEC6ME SNSPECTION FEE „
� SUBJECT70 THE WORK[RS'CONPENSATION PROVISIONS OF SECTICJN 37000F THE LABbR �
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„—�J WnRNINc fA1WFiETOSC�:CURfi WOAKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P,C __
LL SUBJEG7 RN EMFLOYEF TO C(AMINAL PENAlT1E5 AND GVIL FINES UP 70 ONF HUNDRED THOUSAN� ENERGY PERMIT
DOLlAflS(it00.oWj,�NAISDITiONTO THE GpSTOF COMPENSATiOW,6AMAGES AS PROVIDED FOR IN
� SECTION 3108 OF THE LA90fl CUDE,INTEREST,ANU ATTORNEV'6 FEES. FjETENTION FEE: " _ �
d CONSTFUCTION LENDtNG AGENGY PqE-AL7 FEE:
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� i HEREBY APRRM llNDER PENAttt oF PERJUAY TNAT TNERE iS A CtlN57RUCTt4N IENDWG AGENCY __ i
FORTHE PERFORMANCE OFTNE woRK FOR WH��.CN TH15 PEFMIT IS ISSUED(SEC.:399�.GIV C.).
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� i GER7IFY 7}{AT I NAYE R=RD TN15 APPLICATt6N At�STATE'HAT THE A84VE MFOftMA7IQN IS CORftECr TQl'AL FE ES C C•C('1
W I FGqEETp COMPI.V WITHALL CITY AND COUNTY ORDINANCES AND STATE UWS RFLATINGTO BUILOMG V V J4
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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
PRESS
FIRM�Y
JOBSITE
� 1 ��
ADDRESS
APN�OT TRACT
OWNER PUIte Homes
ADDRESS 78401 Von Karman Ste 200
arv Irvine zIP 92612rE�.9497974400
APPLICANT TE�.
CONTRACTOR_SAME
ADDRESS_
CITY ZIP TE�.
ARCH/ENGJ
DESIGNER HOVe Desi n
ADDRESS ewaort enter r
CITY NAWnArt F3Q.MQ_92.6_f OTE�.94976008]2
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOL�OWING REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITfO CONSTRUCT,A�TER,IMPROVE, DEMOLISH,OR REPAIR ANV STRUC�
TUBE, PRIOR TO ITS ISSUANCE,A�SO 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�AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT H E OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE A�LEGED E%EMP-
TION.ANV VIO�ATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS(5500).):
^ 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. 7046, BUSI-
NESS AND PROFESSKXJS CODE:THE CONTRACTORS�ICENSE�,4W DOES NOT APP�Y 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, HOW EVER,THE BUILDING OR IMPROVEMENT IS SO�D W ITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDEF WI�L HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE7.
^I.AS OWNER OF THE PROPERTY,AM E%C�USIVE�V CONTRACI'ING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE�P,W DOES NOT APP_V TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PRO)ECTS WITH ACONTRACTOR(S)�ICENSED PURSUANT TO THE CONTRAG
TORS LICENSE tAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTK)N 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FU�L FOFICE AND EFFECT.
A�ID. No. 517
593
LICENSE CLASS
y� �� �
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DATE_-Lg.�9 I�O/0 1/O N CONTRACTOR S N)I tQ
WORKERS'COMPENSATION DECLARA,TION
I HEREBY AFFIRM UNDER F'ENA�TV OF PERJURY ONE OF THE FOL�OWING DEC�ARATIONS:
I HAVE AND WILL NAINTAIN ACERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,A S PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
41 HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE IABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORMERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
Ems Ins. Co.
CARRIER Pacific
POLICY NUMBER)��(�g�3� � �$7 q
(TEiIS SECEION NEED NOT BE COMP�ETED OF THE PERMIT IS FOR ONE HUPARED DDIIARS(5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUB)ECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000E THE�ABOR
HWITH COMP�Y WITH THOSE PROVISIONS.
RT
CODE,I SHALL FO
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DATE: 5-7Q=0A�PLICANT: PUlte Homes
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�P,WFU�,AND SHAL�BE
SUBJECT AN EMPLOYER'-0 CRIMINA�PENP�TIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOL�ARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND Al-f'ORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT THERE IS ACONSTRUCTION �ENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.).
LENDER'S NAME NAnP III.�
-�ENDER'S ADDRESS
I I CERTIFY THAT I HAVE R.AD THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMP�Y WITH A��CITY AND COUNTY ORDINANCES AND STATE I_,4WS RE�ATING TO BUILDING
�CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PRO PERTV FOR INSPECTION PURPOSES.
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t PERMITi'EE NAME(PRINT)
�SIGNATURE OF PERMITIEE DATE
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