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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
ADDRIESS A 3A 4-1 :42�; ew'-iIc
APN _ LOT �-�— TRACT
OWNER _�GJ_� :r`" �c/
ADDRESS_ 2,64 VC
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY r rer ZIP L.Z-e' rz
ARCFVENG/
DESIGNER
ADDRESS
CITY _ ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFRRAI UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CRY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER. IMPROVE. DEMOUS4, 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 B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSKONSCODE) OR THATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FCR THE ALLEGED EXEMP.
IO
TN. ANY VIOLATKNI OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
D1. AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
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WILL DO THE WO. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NEBS 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
IR HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OF COMPLE-
TKXJ, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
D 1, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
VMO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PL'RSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
D I AM EXEMPT UNDER SEC. _ _ - B. & PC. FOR THIS REASON
DATE __ OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISION%OF CHAPTER
e (COMMENCING WITH SECTION 7000) OF DIVISIONS OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT. -y
LICENSE C S/ LIC. NO. �5� 14P rt +G""��
DATE—'f--'�`-�`—_—_ CONTRACTOR ... - -
WORKERSCOMPENSATION DECI_ARATI
I zY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF 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 PERFORMAN E OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS-OOMPENSA-rINBUR E CARFII1R.ND POLICY NUMBERARE.
CARRIER r f "-
POLK:Y Ny7MBER
(NIS 'NEED NOT BECOMPIETEDOF THE PERMIT S FOR ONE HUNDRED DOLLARS ($1001 OR LESS)
4D-
HFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
NGT EMPLOY ANY PERSON IN AMY MANNER SO AS TO BECOME. SUBJECT TO THE
'1KERS'COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
JECTTOTHEWORKERS'COMPENSATION PROVISIONS OF SECTON 3700 OF THE LABOR
EE,I SHAM FORTHWITH COMPLY WITH THOBE. PR SIONS.f `f� __ APPLICANT..AILURE TO SECURE WORKERS' COMPEN ATIONC ERAGEISUNLAWFULANDBHALLBE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UPTO ONE HUNDRED THOUSAND
DOLLARS 15100,000), iN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 370a OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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 PE9MIT IS ISSUED (SEC. 3007, CIV. C.).
I
LENDER'S NAME__,_
LENDFPSADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABCVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY WITH ALL CIT" AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME RINT}
D SIGNATURE OF PERMI.1 -- I DATE
-� PRESS
FIRMLY
APPLICATION PERMIT PIC
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DATE NUMBER #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW 7
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE/ ❑
PROPOSED USE,
NO. DWEL. NO. f4 O.
UNITS STORIES BEDROOMS �J
DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
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Valuation. ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
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MECHANICAL --'_--'-'-_--...-----"— --
INSPECTION FEE
ISSUANCE
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ENERGY PIC
ENERGY PERMIT AAA r +tress
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RETENTION FEE
PRE -ALT FEE: ��'1 A 1'9: AA„ JTZ D PA,-, -
rTOTAL
TOTAL FEES
COMMENTS_
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RE FIT NO. PAID BY VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLUFNR0D— Ile GOpy, UHLLN—Appucant'S copy