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CITY OF DIAMOND BAR '�`•• � '
-- -���— DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES ��=v'`�^
21825 E.Copley Drive pRESS
(909)860-3195 Fax(909)861-3117
"`-..,;.''� BUILDING PERMIT APPLICATION . FIRMLY
APPLICATION � i�O�PE IT� P/C Q�
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ADDRESS ` ISSUE TYPE OCC
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� DESCRIPTION SQ.Fi. FACTOA PSF ADJ.AREANALUATION
� OWNEFi-BUILDER DECLARATION � SFR/ADD/REM
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I HEREB�AFFIRM UNDER PENALTV OG PERJURV THAT I AM E%EMPT FROM THE CONTRACTORS LF Gef8g0/CBfPOh
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w TURE.PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PEFiMIT TO FILE A SIONED w
� STATEMENT THAT HE OR SHE IS LICENSED WRSUANT TO TME PROV1510NS OF THE CONTRACTORS L6
� CENSE UW(CHAPTER B(COMMENCINO WITN SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
fES510NS CODE)OR THAT HE OF SHE IS EXEMPT THEREFROM AND THE BASIS FOH 7HE ALLEOED EXEMP�
TION.ANVVIOLATIONOFSECTION7031.6BVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICAN7T0 Z Re-Roaf
r A qVIL PENALTV OF NOT MORE 71�M1 FNE HUNDRED DOLLARS(f500).):
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Z WILL DO THE WORIC,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7W�,BU51- J
� NESS AND PROFESS�ONS CADE:7NE CONTN CTORS LICENSE LAW DOES NOT AFPLV TO AN OWNER OF �
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0 TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIID OR
Z IMPROVE FOH THE PURPOSE OF SALE).
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� 70 CANSTRUCT THE FRQIEC7(SEC.�ON,BUSINESS AND PROFESSIONS CODE:711E GONTqAC70R5 LI� VelU0�i0l1 ADJ.AR A
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIRM UNDER PENALTY OF PERJURV 7HAT I AM LICENSED UNDER PROVISKKJS OF CHAPTER �r
d 8(COMMENCWO WITH SECTION 7000)OF DMSION 70FTHE BUSINESSANp PROFES510NS CODE,AND Z
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� I FIEREBV AFFIRM UNDER PENALTV OF PERIURY ONE OFTNE GOLLOWING DECLARATIONS: Z
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� _I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSENT TO SEIF�WSURE FOR WDflKERS' _
Q COMPENSATqN,ASPROVIDEDBYSECTION77000FTHELABORCODE,FORTHEPERFORMANCE W
OF THE WORK FOR WHICH TMIS PERMIT IS ISSUEO. �
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w _�HAVE AN�WILL MAINTAIN WORKEFS'COMPENSATION INSVqANCE.A5 FEWIRED BY SECTKKJ
Q 370a OF iHE LABOH CODE,FOR THE PERFORMANCE OF THE WORI(FOR WHICM THIS PERMIT IS �
ISSUED.MV WORKERS'COMPENS T INSURANCE CARRIE D POLICV NUMBER ARE: CONSTRUCTION
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Z POLICV NUMBER I �� S ELECTRIC
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Z I CERTIFV THAT IN THE PERFORMANCE OK THE WORN FOR WHICH THIS PERMIT IS ISSUED,I �
(} SHALL NOT EMPLOY M1V PERSON IN ANY MANNEF SOAS TQ BE OME SU&IECTT07HE INSPECTION FEE
Uj WORKERS'COMPENSATION LAWS OF CALIF , D A EE HAT IF I SFIOULD BECAME �
S SU&IECT TO THE WORKERS'COMPENSAT PROVI bN OF CTION 370o OF THE LABOF ISSUANCE
CODE I SM FORTHWITH COMPL�W� SE OVI IONS
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p DATE:� 6 �L APPLICANT. . �
J ENERGY P/C ,
J WARNINO:FAILURE TO SECURE WORKERS'CAMPENSATION CAVERAGE IS UNLAWFUL AND SHALL BE
� SUBJECTAN EMPLOVER TO CRIMINAL PENALTIESAND CIVIL FINES UP TOONE HUNDRED T}KK15AND ENERGY PERMIT � r
OOILARS(5100.0001.IN ADDI710N TO THE COST OF COMPENSATKKJ,DAMAOES AS PROVIDED FOR IN
_r.f SECTION37080F1NEUBOACOOE,INTEREST,IJIDATTORNEV'SFEES. RETENTIONFEE:
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w CONSTRUCTION LENDING AGENCY PRE-AlT FEE:
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CC I HEREBV AFFIRM UNDER PENAL7Y OF PERJURV THAT TNERE IS ACONSTRUCTION LENOING AGENCV
n- FOR THE PERFORMANCE OF THE WOflK FOR WHICH THIS PERMIT IS�SSUED(SEC.3091,CIV.G.). �.
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� LENDER'S NM1E
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� I CERTIFY 7HAT I NAVE READ TNIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES
w I AOREE TO CAMPLV WITH ALL CITY AND COUMY ORDINANCES AND STATE LAWS RELATING TO BUILDINO
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUMY TO ENTER UPON THE
� AHOVE�MENTIONED PROPEPTY FOR INSPECTION PURPOSES,� COMMENTS
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� WHITE—Department Copy.YELLOW—Finance Copy.PINK—Assessor Copy,GOLDENRO�File Copy,GftEEN—Applicant's Copy
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ROOF SHEA7HING 8 F7. BUND BEAM
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