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1111A.11 INU 11A
CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
AD I�R, ES
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP L.
APPLICA T L.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL,
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 9 (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-..
TI NI. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
❑ 1, AS OWNER 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 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 OR IMPROVEMENT IS SOLD WITHIN ONEYEAROFCOMPLE-
TKNI, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SATE).
❑ 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 NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAG
TORS LICENSE LAW.).
❑ I AM EXEMPT UNDER SEC. B. d P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
i HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OFTHE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT,
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_ 1 HAVE AND WILL MAINTAIN ACERTIFICATE 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 PERMIT 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 WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
9MS SECTION NEEDNOTBECOMPLETEDOFTHE PERMIT IS FORONE HUNDRED DOLLARS ($100)ORLES4
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 WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (II100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS 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, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
APPLICATIO
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PERMIT
P/C
DATE "!�
NUMBER
#'
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
RWLl
❑
SIDE
❑
PROPOSED USE lip .
e L
i
NO. DWEL. NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION
SQ. FT.
FACTOR PSF
ADJ. AREAIVALUATION
SFR/ADD/REM
Garage/Carport
W
Patio/Dock
LL
Poot/Spa
0
Z
Re -Root
0
Commercial
5
m
Valuation
ADJ.AREA
QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
J�✓t�
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
�Y
RECPT. NO. PAID BY
VALIDATION
WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOWENNUU—HI8 L:Opy, GHttN—nppacam'S ropy