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CITY OF DIAMOND BAR v
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 C. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 c
BUILDING PERMIT APPLICATION"
JOBSITE
ADDRESS Z-3 703
APN LOT TRACT
OWNERfEe . ....YI �NCY
ADDRESS 7376_3 S, iii"-rf Spee.
CITY ZIP f,/�TELI-63S�,
APPLICANT Sc_,TEL.
CONTRACTOR
ADDRESS
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ADDRESS /• - _
CITY r aL�TEL-�
ARCDES el
FINC�
ADDRESS /7.6
CITY 4, `v _PLit _ IZZIP rrL2:iC/7 JEL. 71'Y 13Ii(Llt l
OWNER -BUILD"
Cll) DECLARATION
1 HEREBY aTFI TACK PEVIEil O1 PCICl-1 Z A'� Au EXEMPT fFKMA THC CONTRACTORS LI-
CE_E__'
SE UW FOq 71�LOWING REASON'SEC.7D.TI.S 3�3^�vFT�LLP.^,'.`j ESS -0L COOC. ANY CITYOR
COUM.YWI!IC/R RESADEFYAT70 CONSTRUO'T,ALT'cRIElFiidr,pC MOLISH,OR RE PAR ANY 57RIK
TUBE. PRIOR TO ITS ISSUANCE, ALSO REOU:RCS THE APPLICANT FOR SUCH PERMIT TO FILE A SmGNED
STATEMENT THAT HE OR SHE, IS LICENSED PURSUANT TO THE PROVI51ON5 OF THE CONTRACTORS LI-
CENSE LA'N )CHAPTER S (COAIMENCIIO W.TH SECTION 7000) OF DIVISION 7 CF THE PUS:NESS AND PRO.
FESSIONS COOS) oRTHAT HE OR SHE IS EXEMPT THEREFROA AND THE BASS FOR THE ALLEGED EXEIAP•
TION. ANY V10LATNON OF ECCIION 7001 F BY ANY APPLICANT FOR A PE RM:T SUBJECTS THE APPLICANT TO
A CL PEI:ALTY CF NOT MORE THAN FNE ANY
DOLLARS 1950D))
O L A:OWNEROF THC PROPERTY, OR MY EMPLOYEES WTH WAGES A: TIIE.R SOLE COMP CNW.O N.
WILL DO THE WORK, AND THE STR:,CTURC IS NOT INTENDED OR OFFERED FCR SALE (SEC. 7041. BCSI.
NESS AND PROFESSIONS COOL. THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY 1010 BUILDS OR IMPROVES THF. REON, AW) VAHO DOCS SUCH WOFIK HIMSELF OR NI FOELF OR
THROUGH HIS Oft HER OWN EMPLOYEES. PROVDED THAT SUCH IMPROVEMENTS ARE NCT NTENIDED OR
OFFERED FORSALE IF, HOWEVER, THE BUR.CNGOR IMPROVE MENT Is SOLD WTTHN Oh[ YEAR CF COMP. F.
TION. THE OVIWER BUILDER WILL THE BURDC4 OF PROV'.NO THAT FIE OR SIHC DID NOT BOLD OR
MP110VE FOR THE PURPOSE OF Ma
C. AS OWNER OF THC PROPERTY, AM EXCLUSNELY CONTRACTING 15'T1 LICENCED CONTRACTORS
TO CONSTRUCT THE PROICCT (SCG 7044, BUS'NESS AND PROrt SSICNS CODE. THE CONTRACTCRS U -
CENSE UW DOES NOT APPLY TO AN CMr..R OFAPnOPERTYYMO BUILDS CR MPROVCS THCRCOR AND
N. RACTS FC41 SUCH W'I
WHO COPROJECTS THA OONTRACTONS) LICENSEE PURSUANT TO THE CONTRACT
TORS LICENSE LAW)
O IAM EXEMPT UNDER SCC. B 1 P FORTFCSRCASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I FNERCaY AFr:nu UNDER PENALTY OF PCFLVRY THAT I AM LICENSED U%DER PRO'V'S%ON5 OF CHAPTER
P (COMMENCING WITH SECTION 7000)OF D:AS-0H 0 OF THE BUS -NE SS AND PROFESSIONS =- [.AND
MY LICENSC F.. N FML FM1OE AND EFFECT.
LICENSE CUSS S LIC. NO. 7_61 5-'Q ;2P-0
DATE y l'i CI CONTRACTTDIL_j_ ( S
WOFIKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM CANCER PENALTY OF PERJURY ONE OF THE FOLLOWNO DECLARATIONS /
H HAVE AND W LL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-RNSUP.E FOR WORKERS'
COMPENSATION, AS PROVIDE 0 BY SECTION 5700 OT THE LABOR COCE, FOR TIE PEnrCRMANCC
OF THE WORK FOR WITCH THIS PERMIT IS ISSUED.
-1 HAVE AND WILL LIMNTAN WOnKERS' CLMPCNSATION INS::RANCE.. AS RECUAED BY SECTION
7700 OF TIE LAROFI CODE, FOR THE PERFORMANCE OF TH•L' WCPI'. FOR WHICH THIS PERMIT IS
ISSUED. M'Y.ODKERS' COMPENSVION INSURANCE CARR:[R ASC POLICY NLW:![R ARE.
CARFOER
POLICY NUMBER
(RC SECTIO: NEMNOT BC CO.II•„ CTCOCF T C PEFMT 6 FOR ONE FAYCACD OOLLA'Ci (S-3r;OR LESSL
I CERTIFY THAT N THE PERTORMAN'CE CF THE WORK FCR WHICH TH.S PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECCME SLIWCCT70 THE
WORKERS' COMIO
PENSATN LAWS OF CALIFOnN:A AND AGREE THAT IF I SHc JLD SCCOME
SUBJECT to THE WORKERS' COMPENW.Iom PROV.SANS OF SECTION 77M OF THC LA3011
CODE, 1 SI HALL FOnTMSM TH COMPLY W.TH THOSE PROV.SIONS.
DATE: ��'` APPLICANT, ;
WAnNI4G. FALURC TO SCC WE WORKERS' COMPENSATICN COVERAGE 15 U%LAWFVL, AND SHALL BE
SUBJECT AN EMPLOYER TO CR:M-NAL PENALTIES AND CIVL FINES UP TO ONE HUNDPED THOUSAND
DOLLARS (1100.000L N ADDITION TO THE. COST CF COM-ENSA:ION, DAMAGES AS PRDVDEO FOR N
SECTION 5701 OFTIHE LABOR CODE. INTER C SL AND ATTOL4CYS FEES,
CONSTRUCTION LENDING AGENCY
1HEREBY AFFIRM UMER PENALTY OF FERJURY THAT THERE IS A CONSTROCTION LE 4DNG AGENCY
FOR THE PCRFoRMANIi OF THE WOIK FOR WTPCI THIS PE RM'T IS ISSUED (SEC. 0097, CIV C )
LENDER'S hAME
LENDER'SADCRESS
I CCRT:rY THAT I HAVE READ THIS APPLICATIONAND STATE THA7 THE ABOVE INrCAMAT10N IS CORRECT,
I AGREE TO ODUPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE U1NS PTLA� iNG TO BUILDING
CONSTIIUCTION, AND HEREBY AUTHOrtZE RC PRESENTATNES OF THIS COUNTY TO E 47ER UPON THE
ADOVC-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
P[FUAI rtEE NAME (PRINT)
S.GNA-UIHE OF PC HMI'TE C DA
fft-) PRESS
FIRMLY
APPLICATI / _ P/C
NPERMITUMBS
DATE Gj/�G NUMBER !1
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE El -
PROPOSED
PROPOSED USE AK l
NO. DWEL. NO. NO.
UN1TS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
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TOTAL FEES
COMMENTS
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RECF'T. NO. PAJD 13Y VALIDATION
WI II FE—Department Copy, YELLOW—F"nee Copy, PINK—Assessor Copy, GOLDENROD—Fdo Copy, GREEN—A phwnt's Copy
CITY OF DIAMOND BAR
INISPECTION RECORD
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