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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
M 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS e �� 1er Y�
N LOT TRACT
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OWNER
ADDRESS
CITY Z TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY 2IFI TEL. n) kZa
ARCI-VLG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS ODDE: ANY CITYOR
COUNTY WHICH REQUIRESA PERMRTO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, OR REPAIR ANY STRUC•
TORE. 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 T4E CONTRACTORS LI-
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 700(1) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) ORTHAT HEORSHE ISEXEMPT THEREEROMAND THE BASIS FOR THE ALLEGED EXWP-
TION. ANY MOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 13500).1:
01. ASOWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTOPS LICENSE LAW DOES NOT APPLY T). AN OWNER OF
PROPERTY W40 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 INTFNOED OR
OFFERED FOR SALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LGENSED CONTRACTORS i
TO CONSTRUCT '.HE PROJECT (SEC. 7047, BUSINESS AND PROFESSIONS CODE' THE CONTRACTORS LF
CENSE LAW DOES NOT APPLY TOAN OWNER OF PROPERTY WHO BUILDS OP. IMPROVE8THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUA74TTO THE CONTRAC-
TORS LICENSE UAW.).
LT 1 AM EXEMPT UNDER SEC --- B. S P.C. FOR THIS REASON
DATE OWNER -
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINc'S£ AND PROFESSION£ CODE, AND
MY LICENSE IS IN FULL FORCE ANDD EFFECT.
LICENSE C S y`
It.. NC
DATE / A .'a CONTP.AOTOR, -_
�'.
WORKERS' COMPENSATION DECLAR O
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE CF THE FOLLOYON D LARATIONS:
_ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SGUF INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
L.,.,11E WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, Al REQUIRED BY SFCTON
3700 OF THE LABOR CODE, FOR THE
GGG.PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORK S;CO P_= INSL�.RM!CF CCARRRIJrFj AND POLICY NUMBER ARE
CARRIER–G7L�[JY (/
POLICY NUMBER _
(THS SECTION NEEDNOT BE COMPLETED OFTHE PEPW' IS FOR, ONE HUi•DFI DLYU,RS is100)OP.LESS)
I CERTIFY THAT IN THE PERFORMANCE O: T. HE WORK FOR WH:CH THIS PERMIT !S ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BE COME SU BJFCT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA. AND AG EE THAT IFIS LDBECOME
SUBJ'- TTO THE LNORKERS'COMPENSATKON PROVISION FSECTION' .O OF THE L.'lBD
CgOE SHALL FORTHWITH COMPLY WITH THOSE?R04" ONS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAW FUS, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($1W. 000), IN TO
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH TP.IS PERMIT IS ISSUED (SEC. 3097, CiV. C).
LENDER'S NAME
LENDER'S ADDRESS
I 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
CONSTRUCTION, 'D HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MEkT D PR RTV INSPECTION PURPOSES.
PERM N 1
SIGNATURE OF PERMq7W DATE
PRESS
FIRMLY
APPLICATIO PERMITPIC
DATE (� -co NUMBER #
ISSUE TYPE OCC
DATE. CONST. GROUP
ZONING SETBACKS
FRONT RW E_ -
REAR REAR C
SIDE/SIDE STREET _ RW C
SIDE A
PROPOSED USE {/A �i 4
NO. DWEL. NO. NO.
UNITS _ STORIES _ BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM _
�
GaragB/Carport
LLIJ
Patio/Dock
LL
ZRe
P—DOI/Spa
-Roof
Commercial
ADJ.AREA
QIlANTITY DESCRIPTION�fki 1 FEE
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CONSTRUCTION _�-41�. [•Q_
PLAN REVIEW ,--_...--------_—'---
ELECTRIC _---_—_--_—__
PLUMBING -----_—_----. —
MECHANICAL
INSPECTION FEE -
ISSUANCE
SMIP -----�—�.0
ENERGY P/C
P/C ---._...-- ---'---'--- ---
ENERGY PERMIT
RETENTION FEE: __ _
p_
PRE -ALT FEE: [�- 2t_______-,—
TOTAL FEES
1
COMMENTS_._
RECPT. NO. PAID BY —_ VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy