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CITY OF DiAMOND BAR
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21825 E.Copley Drive
r (909)860-3195 Fax(904)$61-3117 PRESS
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� SUBJECTANEMPI,OVERTOCRIMINALPENAI.TIESANDCiVILFINE5UPTOONEHUNDflE07HOU5ANI] ENEFIGYPERMIT .___,,. .
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� ICERTlFYTNATIHAVEftEA0i4t5APi'UCATIONANDSTATETNRTTHeA60`lEitJFORMAilONiSCORRECL TQTAL FEGS �-' « � � �r r`�.• ' �J�'
� I hGkEE TO COM('LYWKII ALl CITY ANO COVNTV OROINNNCES Ah'D SiATE tAWS RELATING 70 BUIL�ING ��V
� CON`aTRVCTION,AND HEHEBV AUTHORIZE REPRESENTATIVES OF THI5 COUNTV TO F.NTER UPON THE
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cITY of DIAMOND sr�R�X�',1 r��
DF,PARTMENT OF COMMUNI'T'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
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ADDRESS K������I�
APN LOT TRACT
OWNER 3L2„T nj�7LSCr'
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CITY rV/.amc7N I�/J°�'CZIP TEL._
APPLICANT TEL.
CONTRACTOR/e�-�TRi[nJ�i 41/t
ADDRESS?IC.�R-pse3'
CITY�YS--ZIP 411-1 TEL.�IIY.S?A do
ARCWENG/
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. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR :iHE 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-
FESSIONSCODE)ORTHAT HE ORSHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^I,AS OWNER OF THf_PROPERTY,OR MY EMPLOYEES W ITH 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 I:ODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS ON IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWIV EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN 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 0 WNER OF TH'E PROPERTY,AM EXCLUSIVEI.V CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(5EC. 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 W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^I AM EXEMPT UNDER SEC. B. 8 P.C. FOR TNIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOFICE AND EFFECT.
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LICENSE CLASS�
LIC
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DATE i 3 �20'03 CONTRACTOR� �-Ct=
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
I
COMPENSATION,AS PROVIDED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORN FOR WHICH THIS PERMIT IS ISSUED.
I NAVE AND WILL M/11NTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOFI CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV
W
CO
MPENSATION INSUR NCE CARRIER AND POLICY NUMBER ARE:
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RK
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RS
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CARRIER J[! �'C-�' N/I�--�/�-�G
POLICY NUMBER_�fJ� (7p] ��� 7b�' 7�
(EFiIS SECTION NEED IVOT BE OOMPLETEDOF THE PERMR IS FOR ONE HUNDRED DOLLARS(5700)OR LESSI.
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLO\'ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE T�I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PRO DN F CTI 37000E THE LABOR
CODE
TH WITH COMPLY WITH THO P VIp
IS
H
F
OR
A/I
/
P
)
DATE: --��P�V--�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(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OI"THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE AROVE 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(PRINTI
SIGNATURE OF PERMITTEE DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
0,01,9