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� � DEPARTME?�.rT OF COMMUNITY&DEVELOPIvIENT SERVICES ��� �
w � 21825 E.Copley Drive
� (9Q9)$60.3195 Fax(909)861-3117 PRESS
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� SECTION 3�08 OF 7HE LABOR CODE,INTEAEST,AhDATTOqNEY'S FEES AETENTION FEE
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� I CEFTiFV THhT I NAVE READ THiS APPLICATIONAND STA1E THAT THE ABOVE INFORMATION i5 CORRECT
� I AGREE TO COMP�Y WITH ALL CITV AND COUNTV O(iDINANCES AND STATE LAWS FELATING TO PUILDING
� CONSTRUCTIpN,Aryp HEflE6Y AUTHORRE qEPRESENTATNES DF TH15 COUNTY TO ENTER UPUN THE
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FECPT NO PAID BY VALIDATION
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CITY OF DIAMOND BAR
DEPARTIVIENT OF COMMUNFfY&DEVELOPMENT SERVICES 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE i
ADDRESS t too SDaI ern (I) .
APNLoT TRACT
OWNE171— .-...-
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ADDRERS i 1 12() at yi pee, .
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CITY U•korliteiti FA y(4 ZIP I 7 6,1 TEI..000374-i-V.C.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
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 REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIRANY 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 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 ALLEGED EXEMp-
TION ANY VIOLATION OF SECTION 7031 5 BY ANY APpLICANT Fon A FERMI SUBJECTSI HE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500))
0 I.AS OWNER OFfHE PROPERTy OR MY EMPLOYEES WITH WAGES AS 1HEIR SOLE COMPENSATON,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,SUSI-
NESS AND PROFESSIONS CODE THE CONTRACTOFiS 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)
0 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 WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC B&PC FOR THIS REASON
DATE air• ^ OWNER, 1....A1WaIIfrAllrfr ..- ...-
/
41if
LICENSED CONTRACTORS DECLARATI e
I 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 AND EFFECT
LICENSE CLASS LIC NO
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM uNDER pENALTY OF pERJURY ONE OF THE FOLLoWING DECLARATIONS
I HAVE AND WILL 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 WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOFI THE pERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS'COMpENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
POL1Cy NUMBER
(THIS SECTION NEED NOT BE COMpLETED OF THE PERAUT IS FOR ONE HUNDRED DCUARS($103)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN 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 pROWSONS OF SECTiON 3700 OF THE LABOR
CODE,I SHALL FoRTHWITH coMPLY WITH THOSE PROVISIONS
)
DATE APPLICANT
)
1 WARNING FAILURE TO SECURE WORKERS'COMpENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYEF110 cRIMINAL PENALTIES AND MIL FINEs UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
,I SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
J CONSTRUCTION LENDING AGENCY
— i HEREBY AFFIRM UNDER PENALTY OF PERJUFIy THAT THERE IS A CONSTRUCTION LENDING AGENcY
- FOR THE PERFORMANCE OF THE WORK FOR WHiCH THIS PERMIT IS ISSUED(SEC 3097,cni C)
5
LENDER'S NAME
- LENDER'S ADDRESS
R 1 cERTIFY THAT I HAvE READ THIS AppLICATIoN AND sTATE THAT THE AsovE INFoRmATtON ts coRREcT
L' I AGREE TO COMPLY WITH ALL CITY AND COUNT,/ORDiNANCES AND STATE LAWS RELATING TO BuiLDING
rs CONSTRUCTION,AND HEREBY AUTHoRIZE REPRESENTATIVES oF THIS COUNTY TO ENTER UPON THE
5... ABOvE- TIONED PROPERTY FOR INSPECTION PURPOSES
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SIGN,IIIMI:F PERMITTEE DATE
APPLICATIOtq LJ2 il PERMIT PIC
DATE NUMBER 00#
ISSUE 'TYPE OCC
DATE ONST. GROUP
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TOTAL FEES --11,SD
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RECPT NO PAID BY VALIDATION
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