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DEPARTMENT OF COMMU1vITY&DEVELOPM NT SERVICES
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DIAMOND BAR d :JAV
CITY OF DIAMOND BAR
DEPARTMENT OP COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 as5; CS 2-3c4(909)860-3195 Fax(909)861-3117
BPILDISG PERMIT,APrLICATIQN
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.o OWNER-BUILDER DECLARATION
cm I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U.
W. LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODEANYCITYOR
= COUNTYWHICH REQUIRESA PERMITTOCONSTRUCT.ALTER.IMPROVE,DEMOUSH. ORREPAIRANY STRUC-
LT_ TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED
>-• STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS u-
..J CENSE LAW(CHAPTERS(COMMENCING IMTH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
CC FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEFIEFROM MOINE BASIS FOR THE ALLEGED EXEMP-
LII TON,ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS DiE APPUCANT TO
CL A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(3500).
0 0 I,AS OWNER OFTHE PROPERTY,OR MY EMPLOYEES WITHWAGESAS THEIR SOLE COMPENSATION,
•-•-• WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,SUM-
LLI NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
I- PROPERTY WHO BUILDS OR IMPROVES'THEREON.ANDWHO DOES SUCH WORK HIMSELF ORITERSELF OR
• Z THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEAENTS ARE NOT INTENDED OR
LLI ,OFFERED FORSALE IF,HOWEVER.THEBUILDNGORIMPROVSIE4T IS SOUMNITHINONEYEAROF COMM&
2 • TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
I 'i IMPROVE FOR THE PURPOSE OF SALE).
-.1 CI L AS OWNER OF THE PROPERTY.AM EXCWSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
ca To CONSTRUCT THE PROJECT caec. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS 1.1-
..c CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEFIEON,AND
CI) INHOCONTRACTSFOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTOTHE CONTRAC-
co TORS UCENSE LAW.).
-3- I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM UCENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 30f THE BUSINESS AND PROFESSIONS COOE,AND
MY UCENSE IS IN FULL FORCE AND EFFECT.
UCENSHLASS LIC. N0. 64
DATE 9- CONTRACTOR n1111111L11/1111/1 I AMA
6)(19e WORKERS COMPENSATION DECLARATION
I HE AFFIRM UNDER PENALTY Of PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND 1VIU. MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
.Aiefet AND MUT/AMAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
7 3700 OF THE LABOR COOS. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED,MY WO- ., DENSA ON/NSU- E CARRIER MO P•LICY 311.{MB• -
CARRIER ...3 E:
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PaeLCY NUMBER I 11:4111K.44 4v371Mlit li
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ink7AWNEID• • : ••• .•OFRIE PERK IS FOR ONEKNXICOCCUARS(5100)ORLESS).
I CERTIFY THAT IN TNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON WAN?MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SU3JECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
* .74 1111}4 CO/APLY WI THOSE_COVISI S.
DATE: 1 viE-n-n lAPPLICANT: I I-0 flUrrieS
WARNING: FAIUJRE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CPAL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100.000),IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 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 OFTHE WORK FOR VAllai THIS PERMIT IS ISSUED) C. 3097,aV.a).
LENDER'S NAME
tSt,..dSM.irrj.liatb:S....
LENDER'S ADDRESS
MI
CERTIFY THAT I HAVE READ THIS ApPucATKX4 AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVEMENTIONED PROPERTY FOR INSPECTION PURPOSES.
C*0
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SIGFUEOPPERIE DATE
APPLICATIONS
DATE
r'..
a" 0 I PERMIT Ut 64 P/CO I ...c9p,3
NUMBER #
ISSUE
DATE
OCC
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0
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co
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