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DIAMOND 01_
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
JOBSITE
ADDRESS �l? IAJL11 t �1—
APN LOT TRACT
OWNER—Ajjj 2AP.P46L.
ADDRESS Skivup
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS ^
CITY ZIP Z .7 TEL. 6 rLYC
ARCVVENG!
DESIGNER 19_0j If, J rt
CITY k'.11'VL ZIP TEL l
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOWING REASON (SFC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CI7YOR
COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY 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 D (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 FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (11500).):
D I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES ASTHEiR SOLE COMPENSATION.
WILL DO 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
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 ORIMPROVEMENT IS SOLD WITHINONEYFAROFCOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WRH+ LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSION$ CODE. THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLYTOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHX)CONTRACTSFOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC-
TORS UCFNSE LAW.).
D I AM EXEMPT UNDER SEC. _-_B. & P.C. FOR THIS REASON
DATE _ _ OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
Y (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS CLL/ UC. NO A,
DATE�Q-"�2"UI3 CONTRACTOR K?
WORKERS' COMPENSATION DECLARATIO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECL ATIONS: J
__I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR W
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORM
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37W OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED, MY WORKEERSS''+CO/1MPPEENS(—
A'TTION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER _�L.8 / (]
POLICY NUMBER , higf�Y � I.7 i^7 & Jr �
THIS SECTION NEEDNDTDE COMPLETED OF'I-E PERNtiT G FOR ONE HUFDREDDCU.ARS (51DO)OR LESS)
I CERTIFY -HAT 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 B
SUBJECT TO THE WORKERS' COMPENSATION PROV S OF S ON 00 OF 7 OR
CODE.. I SHAALL_FFOITT,HW ITH COMPLY W ITH THO ISI
DATE:Z Z"�U APPLICANT:
WARNING: FAILURETO SECURE WORKERS' COM E TION COV AGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIE D CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000). IN ADDITIONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCEOF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC 3097. CIV. C.).
LENDERS NAME
LENDER'S ADDRESS _
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMA7K)N IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
AROVE-MENTIONED PROPERTY FOINEO URPOSES.
V
PERMI EE LAME (PRINT)
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SI E DATE
PRESS
FIRMLY
APPLICAT ON PERMIT PIC,i
DATE Z �'J"e! NUMBER #
ISSUE 4 TYPEA� � OCC
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DATE CONST, GROUP
ZONING SETBACKS
FRONT _ RW 0 -
REAR C
SIDE!SIDE STREET RW G
SIDE
O;SEED/USE 2 G
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O. DWEL. NO. NO.
UNITS STORIES _ BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
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Garage/Carport
WPatio/Deck
LL
Pool/Spa
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Re -Roof
Commercial
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Valuation A OJ.AREA
OU ITV DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C �- .. --+ • • �. •- }
ENERGY PERMIT
RETENTION FEE: _
PRE-ALTJFE
d
TOTAL FEES /3 O` /
COMMENTS
RECPT NO. PAID BY VALIDATION
WHITE—Department Copy, YELLOW—Finanoe Copy, PINK—Assessor Copy, GOLDENROD —File Copy, GREEN—Applicarit's Copy
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