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CITY OF DIAMOND BAR � '
��F� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES \_ -'�
� . 21660 E.Copley Drivc Suiu 190
(909)86a3195 Fax(909)861-3117 PRESS
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d
� I HEREBYAFFIFM UNOER PENPLTY OF PERJURV THATTHERE IS A CONSTRUCTION LEN�ING AGENCY
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION
PRESS FIRMLY
APPLICATION
DATE
PERMIT 1.5d )70 P/C O1-C
-2-7-ot, NUMBER #
ISSUE
DATE
rri(oti TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
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SIDE/SIDE STREET RW o
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STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
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CC OWNER-BUILDER DECLARATION
0
CI I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LIIJJCENSE LAW FOR
THE FOLLOWING REASON(SEC. 7031 6 BUSINESS AND PROFESSIONS CODE ANY CITY OR
2 COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUCTIJRE. PRIOR TO
ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED LU
M STATEMENT THAT HE OR SHE IS LicENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
8 CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE)OR
THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEM PCa TION.ANY VIOLATION OF SECTION
7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO .--A clyILgENALTY OF NOT MORE THAN FIVE HUNDRED
DOLLARS($500)).
2,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI-
NESS AND PROFESSIONS CODE.THE CoNTRACTORS LICENSE LAW DOES NoT APPLY TO AN OWNER OF C/3 PROPERTY WHO
BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR CC THROUGH HIS OR HER OWN
EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR ILL! OFFERED FOR SALE iF, HOWEVER.THE
BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLECI TION,THE OWNER-BUILDER WIU. HAVE THE BURDEN
OF PROVING THAT HE OR SHE DID NOT BUILD OR Z IMPROVE FOR THE PURPOSE OF SALE).
LLI 0 I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS CC TO CONSTRUCT THE
PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI. LL CENSE LAW DOES NOT APPLY TO AN
OWNER OF A PROPEFITY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW).
0 I MI EXEMPT UNDER SEC B P.0 FOFITHIS REASON
OWNER
4111"..-4.^ .1111.112g.--/
LICENSED CONTRACTORS DECLARATI
I HEREBY AFFIRM UNDER PENALTY oF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH
SECTION 7000)or DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY UCENSE IS IN FULL FORCE AND EFFECT.
LIC. NO
LICENSE CLASS
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
HEREBY AFFIRM UNDER PENALTY OF PEFUURY 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 PEFIMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANcE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE,
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKEFIS'COMPENSATION INSURANCE
CARRIER AND POLICY NUMBEFI ARE
CARRIER
POLICY NUMBER
(THIS SWIM NEED NOISE COMPLETEDOFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($103)OR LESSL
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 PROVISIONS OF SECTION 3700 OF THE LABOR CODE,I SHALL
FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE. APPLICANT:
WARNING FAILURE TO SECURE WoRKEFIS'COMPENSATION CoVERAGE IS UNLAWFUL.AND SHALL BE SUBJECT AN EMPLOYER
To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST
OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR cODE,INTEREST,AND ATToRNErs FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV.C)
LENDER'S NAME
LENDER'S ADDRESS
cERTiFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOvE INFORMATION IS CORRECT. I AGREE TO COMPLY
WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
STRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES oF THIS COUNTY TO ENTER UPON THE
VE D-PROPERTY FOR INSPECTION PURPOSES.
-J
03
44C
C/3 CO
F-
WHITE—Department Copy,YELLOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant s Copy
DATE
CITY OF DIAMOND BAR INSPECT!ON RECORD
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