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1„� CITY OF DIAMQND BAR
� � DEPARTMENT OF COMMllNITY&DEVELOPMENT SERVICES +^�'�
2166Q E.Copley Drive Suite 190 � / �
(909)$60-3195 Fax(404?�1-3117 �� ����`�V��'� �� t PRESS
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ARCHIENG/
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� DESCRIPTION SQ.F7. FACTOR PSF ADJ.AREMJA�UQTiON
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O i HEREBY AFfli9A UN(7ER PENALTY OF PERNFlY TNA7 1 M1 EXEMPT FFlOM TME CONTMCTORS LJ- G8298/C81p0IS
CENSEUWFORTMEFOII(WlINGREASON(SEC.7q31.5BUSINESSAN�PROFE5510NSCADEANVpTVOR (�
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NRE.PRI�R Td ITS ISSUfNCE,ILL50 REOUIRES TNE A4KICANT f-0R SUCH PEftMf7 7�FllE A SIQNGD �
STATEWENT THAF HE QR StfE IS UCEN5E0 PURSUANT TO 1HE PpOYISIONS OF TNE COhITMGTOR9 LI- '
CEN5E LAW(CFiAPTER O 1CM5MMENCINO WITH 9EGTION 7000�OFDIVISION 3 OF THE BUSiNE55 AND PR0. �'�' POOVSp3
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F A CML PENALTY OF NOT u�t7RE R WI FIYE MUN�fiEO DOLURs(f5oo).):
� OI.A90WNEROFTHLPPQPERTV.ORMVEMPLOVEESWITMWAGESASiN€IRSOIECOMPENSATiON, {� �qm1116ICiai
WILL Dp TME WORK Ml0 7HE STRllC7URE iS N6T iNT£NDE6 Oii OFFERE6 foR SAtE(S£C,70u,Bu91- J
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PROPEHTY M1RM�BUNAS aR INPROVES THEpEON,ANd Vh10 DOES SUCH WORK HIMSEI.F OR HERSELF 4R
� THROUCiH HIS OR MER ON'N EM%AYEES,PItOVIDED TNAT SUCH iMPROVEMENTS ARE NOT ttiTENDGO OR m
L� .OfFEREDF4RSKEIf,HOWEYER'mEBl7iLCNNGORDAPROVEtAENTiSSIXAWtTNINOPlEYEAftOFCRMPIb
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W O I,AS ONMER OF THE PROPERTY,AM E%CLUSIYELV CANTMCTING WtTH UCEN5ED CQtiTRAGTORS '
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� $HALL t10T EMPIOY ANY PEFSON IN ANY MANNER 54 AS Tp BECAME SV&IECT TU THE '
� W4RKER3'C�>MPENSATION LAWS OF CALIFOpNIA AND AGREE THAT IF I SHOULD 6ECAME INSPECTiON FEE ,
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WARNIN�:FAIIURE l0 SEGURE WORKERS'COMPENSATION COVERAQE i5 UNLAWFUL,AND SHAII 8E
�y Sll&IECT AN EMPLOMERTO CR�MiNAI PEtJAlTiES AND GiVtE FINES UP TOONE Ht7NORED TNOUSAND ENEF4CzY PERMIT
Doti.ARS(51ap.000}.{N AIX31TfON SO THE C6ST oFCOMPEN5AT1oN.DAMAGES AS f ROVIDED FOR IN -
� SECT10N37oM�THELAHORCODE.INTEREST,ANDATfORNEY'SFEE3. RETENTIONFEE:
� _. _
a CONSTRUCTiON LENDIN�a AGENCY PRE-AlT FEE:
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Qi NER£SYAFFIHM UtM�Eft PENALTY OI'PERJURY TMATTHERE IS ACONSTRUCTIpN I.ENDING AGENCY ^!._..i
FOR THE PEflFORMiiNCE DF TME WORK FOR WHICH THIS 7ERMIT IS ISSUED(SEC.3097,CIV.C.j.
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� IENDER'S NAME_ _„_ . � _
F' 4EN�ER'SADpRES5
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6
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTTY 8r. DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190/�j//� [� n
(909)860-3195 Fax(909)861-3117�K/��� �V� �V� '-�' �"'
BUILDING PERMTT APPLICATION
PRESS
FIRMLY
JOBSITE�,Lgy�t'�/'Tai J
ADDR SS
APN LGT TRACT S'.226 7
OWNE�u IJ.���CCtr�
ADDRESS 1 ��101/o„rar�u„�Su.�X00 Tr/,'„c,
CITY'Aw•..a��-(3�-�
-'-ZIP/7 TEL.
APPLICANT.�a.w I'v/>k Now.cr TEL.��'1� 7i7-S��Y
CONTRACTOR°' �c�c'
ADDRESS�i�;.tw�/n".154.r1xr'�/!!' J'�� ,T�2, ',
CITY-���'ZIP� b TEU,S/�/7'f�'yyc��g
ARCH/ENG/
DESIGNER�p4t'k Gross� �Stot:A,�
ADDRESS� 'SS/�1 ..Tye Iti'n
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CITY��� ZIP fZ7G.S TEL.
OWNER-BUILDER DECLARATION
1 HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLCAVING REASON (SEC. 7031.5 BUSINESS AND PROFESSK)NS CODE: ANY CITY OR
COUNTY WHICH REWIRESAPERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRpR TO ITS ISSUAJJCE,AL50 REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
57A7EMENf THAT HE OA SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)ORTHAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIS FOR THE ALLEGED E%EMP-
TTON.ANY VpIATK%V OFSECTION 7031.5 BV ANY APPLICANT FOA A PEAMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATK)N,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTOAS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BLINDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THRWGH HIS OR HER ON'N EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUKDER WILL iIAVE THE BURDEN OF PROVING THAT HE OR SHE OIO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I,AS OWNER OF TfiE PROPERTY,AM E%CLUSIVELV CONTRAC71N0 WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
Wh 1000NTRACTS FOA SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDEFI PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (CCNAMENCMIG WITH SECTION 7000)OF DIYISKNI 3 OF THE BUSINESS AND PROFESSKNS CODE.AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRACTOfI
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATK)N5:
I HAVE AND WIL L MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATKYN,AS PROVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WI11 MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTKNJ
37000E THE LIV30R CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV VAJRKERS'COMPENSATKKJ INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLK:Y NUMBER
(I10.55ECi1CN NEEDN07 BE OOA4R-ETED OFTHE PEAMR IB FOR ONE WN,Df1EDDCLLARS(5100)OR LESS}
I CEATIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'GOMPENSATKNJ LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATK)N PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHAIl FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPIO�/ER TO CAIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND
DOLLARS(5700,000),IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN
SECTON 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UIJDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV C.).
I
LENDER'S NAME
LENOEA'S ADDRESS
�I CERTIFY THAT 1 HI1VE READ THIS APPLICATK)N AND STATE THAT THE ABOVE INFORMATK%I IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY ANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
�CONSTRUCTlON,AIVD HERESY AUTHORRE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTKNJEb PROPERTY FOR INSPECTKJN PURPOSE
1 -
F PERMITTEE N (PRINT)-���-
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�SIGEOPEIEAT
E-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy; GOLDENROD--File Copy,GREEN-Applicant's Copy