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1��_ CITY OF DIAMOND BAR
DEPART?�SENT OF COMMUNITY&DEVELOPMENT SERVICES
a 21660 E.Copley Drive Suite 190
(909)860-3195 Fa�c(909)851-3117 PRESS
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� STATEMENT THAT HE OR SHE IS LICENSED WRSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
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❑I AM IXF_MPT UNDER SEC. B.S P.G FOR THIS REASON Q
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� DATE OWNER �
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� LICENSED CONTRACTORS DECLARATION W
� I HEqEBYAFfIRM UNDER PENALTY OF PERIURV THAT 1 AM LICENSEO UNDER PROVISIONS OF CHAVTER �
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��� AAV LICENSE IS IN FULL FORCE AND EFFECT.
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� WORKERS'COMPENSATION DECLARATION �
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� I HEREBY AFFIRM UNDER PENALTY OF PE0.IURY ONE OF THE FOLLOWING DECLARATIONS: Z
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� I MAVE AND WILL MAINTAIN A CERIIFICATE OF CONSENTTO SELF-INSVRE FOR WORKERS' _
� COMPENS ,�5 PROVIDED 9Y SECTION 3700 OF TME U1BOR CO�E,FOR TME PERFORMANCE W
OF ORK FOR WHICH THIS PEFMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKEflS'COMPENSATION INSUH�NCE,AS FEWIRED BV SECTION
Q 3]00 OF 1HE LPBOR GODE,FOR THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PEPMIT IS �� I
ISSUE�.MY MNRKEFbR79APEN5A710N INS RANCE CAR PND POLIC�Y NV1MBER ARE: CONSTRUCTION
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W I CEFTIFV THAT IN THE PERFORMIWGE OF THE WORK FDfl WMICH THIS PERMIT 15155UED,l MECHANICAL
Z
L} SHALL NOT EMPLOY ANY PEfl50N IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE +
� WORKERS'COMPENSATKKJUWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE
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RETENTION FEE:
OGONSTRUCTION LENDWG AGENCY P/��J�4 LT F�E I pITY O�F7�� 1 "
� 1 HEREBYAFFIRM UNDER PENALTV OF PERJURY THAT THEflE IS A CONSTflUCTION LENDING AGENCY �-"■ v �� fi)I ll`IG����.� ( �
� FOR TNE PEAf-0RMANCE OF TNE WORK FOR WHICH THIS PERMR IS ISSUE�(SEC.309].CIV.C.).
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� LENDER'S NAME •
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� TOTAL FEES
w I CERTIFV THAT I HAVE REPD TMIS APPLICATION AND STATETHAT THE ABOVE INFORMATION IS COHRECT
I AGREE TO CAMPLV N7TH ALL CITV AND COUNTV ORDINANCES AND STATE lAWS RELATING TO BUILDING } r /A,
� COf157RUCTION,AND HEREBV AUTFIORIZE REPR'eSENTATNES OF THIS COUNN TO ENTER UPON THE � D�{t y .�- '/�,Y _L /)
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ULtMOSI)IL%I I
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICA
JOBSITE
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ADDRESS
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APN�OT TRACT
OWNER t-4-V�J
ADDRESS I,Tc./A k2cib a-, L
CITY J),.s-mmA.A,-ZIP TE�.
APPLICANT 6 id TE�.
CONTRACTOR fL w�f)u 12&;GC 0 iJ
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CITY�A„*I.it SQ
ARCWENGJj
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DESIGNER NER
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ADDRESS
CITY ZIP TE�.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�AW FOR THE FO��OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,A�TER.IMPROVE, DEMOI.ISH,OR REPAIR ANY STRUC.
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI-
CENSE�AW(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 A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.6 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DO��ARS(5500).):
^ 1.AS OWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION,
WI�L DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044,BUSI-
NESS MID PROFESSIONS CODE:THE CONTRACTORS LICENSE(AW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS 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 BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E-
TION.THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE IAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE�AW.).
^I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
/
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LICENSE CLASS LIC. N0.J
5'�-+
DATE o_T2,!O 0 CONTRACTOR
WORKERS'COMPENSATION DECLARP,TION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARA,TIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENS,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF OAK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IJaBOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
D
POLICY N4MBER ARE:
ISSUED. MY WORKEFIreSMPENSATION S NCE CAR AN
C
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CARRIER V,••/J
POLICY NUMBER
(THIS SECTION NEED NOT BE OF THE PERMIT IS FOR ONE DOLLARS($100)OR�ESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�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(ABOR
CODE,I SHAL�FORTHWITH COMP�Y WITH a'.'y9I!-P'G'V
IISIONS.
VI
DATE: i-APPLICANT: J C we oj,�,S
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST.AND Al-fORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION �ENDING 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 COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERMITi'E NAME(PRINT)
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