HomeMy WebLinkAbout20825---� R� CITY OF DIAMOND BAR
I DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
d 21825 E. Copley Drive
(909) 860-3195 Fax (909) 861-311T PRESS
BUILDING PERMIT APPLICATION r - FIRMI V
JOBSITE
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APN LOTS_ TRACT
OWNER (A'
ADDRESS a . I GYi:LF1dr 1'
CTTY�,f--,./Ji e'xoC Vz� ZIP '% t % (- S TEL S;'U (7- > "'1 'S.S
APPLICANT �E
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBYAFRRM UNDER PENALTY OF POWURYTHAT I AM EXEMPT MUM1M CONTRACTORS LL
COMM LAW FORTHE FOLLOWING REA50N(SEC
.TWI.5 BUSINESSAND PROFESSIONS CCDEANYGLYOR
CGINttmH REOUIRESAPEROTTOWNSTg T.&TERIMPROVE.UMCUSH,ORAEPAIRI SMI
TURF PROP TO RC ISSUANCE ALSO REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROWONS OF THE CONTRACTORS LL
CENSE LAW (CHAPLIN 9 (WMMENCWG WITH MOTOR TWU) OF DIWSION s OF THE BUSINESS AND PRd
PERSONS CODE) ORTHAT HE OPENS IS FXEMPTTHEREFROMAND THE BASIS FORTHE ALLEGED EXEMP-
TON.ANYVOUTON OF SECTION 703t$ BYANYAPPLICOM FORA PEWATSUR ECTS THE APPLICANTTO
A CML PENALTY OF NOT MORE THAN FINE HUNDRED DOLLARS JR.N:
ULMS EROFTIEPROPEg .ORMYFMPLOYEESMNWAGESASTIEIRSIX COMPENSATION,
,,,LW THE WOW(, MID THE STRUCTURE IS HOT INTENDED OR OFFERED FOR SALE (SEC. TOµ, BUSF
NE. AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OMMM OF
PROPERTY WHO BUILDS OR IMPROVESTHEREON, ANDWHO DOES SUCH WORK HIMSELFCR HMSEIFOR
THROUGH HIS OR HER OWN EMPLOYEES, PROVOED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED MRSALE IF, HOWEVER THE BUILDING OR WPPMEMENTISWID WITHIN WE YEAR OFCOMPLS
TON. THE OWNERW WER POLL HAVE THE BURDEN OF PROWNG THAT HE OR SHE DO NOT BUILD OR
WPR0t FORTHE WRPoSEOFSARTY
OAAIUCT TH PROJECT(SE.7Y , BUSINSNELYWMMCTNG IONS CO ETHELICENSOCOMMCTORS
RSU-
TOWI-Aw TTHEPROJECT(GEC.TOµ,BUSINESSAND PROFESSIONS CODETHEWMMEON,AD
MOC NT WESFOTAPPLYTOJE TS PER VATHAC PROPERTY WHOBUIDS SED R IMPROVER PURSUANTMTHE OONTvNO
WHOWMRACTSFORSWNPPOJECTS WITIAWMPACLOR(5)LICENSEOPUgSUAMTOTHEWMMG
TORsucENseuw.).
U I AM EXEMPTUNDER SEC, B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
IHEREBYAFFWMUNDERPEN4TYOFPERJURYTHATIAMLIENSMUNDfRPROVIS2NSOFCHAPTER
"COMMENCING PATH SECTION rWS) OF DIVISOR 3OF THE BUSINESS AND PROFESSIONS WOE, AND
MYLICRNSE IS IN NLLFORLEAND EFFECT.
LICENSE CLASS LID. NO.
DATE COMPACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATION S.
_I HAVE AND WILL MNNTAM A CERTIFICATE OF CONSENT TO SELF INSURE FOR WORBERE
COMPENSATON,AS PROVIDED BYSECTONSPAOFMCO
DE. OE FORTHE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' WMPENSATON INSURANCE AS REWIRED BY MOTION
ST00 OF THE UWq CODE, FOR THE PERFORMANCE OF THE WORK FOR MICHT IS PERMR IS
ISSUED. MY WORKERS' COMPENSATION MSURANCE CARRIER AND POLICY NUMBER ME
CARRIER
POLICY NUMBER
jINISSECIMNxE®TArBEOM40. W ®aFTHE Fll&Yf 5 PoRIXJEµPAfA'll®py1N15 rs10))gLLEssI
I CERTIMTHAT INTHE PERFORMANCE OFTHE WORK FDA WHICHTHIS PERMIT IS USUM, I
"LLNOTEMPLOYAM PERSON INANYMANNER W AAMBECOME SUBJECTTOTHE
WORKERS' COMPENSATION JAWS OF CAUFOBNWAND AGREE THAT IF I SHOULD BECOME
SUBIECTM THE WORKERS-COMMNSATON PROMONSOFSECTON]TOOOFTHE IABOR
CODE. I SHALL FORMLNM COMPLY W IT I THOSE PROMSONS.
DATE: APPLICANT:
WARNING FNUREMSEWRE WORKERS' COMPENSATIONCOVEMOE IS UNIAWFUL.ANDSHALLBE
SUBJECT AN EMPLOYERTO CRWMAL PENALTIESAND gWLFINES UPTOONEHUNDREDTHWSANO
DOLLARS(SUFOPS, INADDDIONTOTHECOSTOFCOMPENSATON, DAMAGES AS PROMOM MR IN
SECOWLY 00FTHELABOR CODE INTERMT.ANDATTONNEWS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FW THE PERFORMANCE OF THE WOW MR WHICH THIS PERMIT IS ISSUED ISEG 30U. CIV. C.).
LENDERS RANE
LENDERSAWRESS
ICER "F TIMA REPDTHISAPPUCATIONMOSTAnE TMEMB INFORMATONISWRKE ..
I AGREE TO COMPLY MN ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CCNSTRUCTIW,ANDHEREBYAUIHORIZEAePRESENTATIVESOFTHIS WUMYTOFMERUPONTIE
ASOV E-MEMKINED PMPERtt PoR INSPECTION PURPOSES.
PE ITIEE9NAE"1" r _
SIO RE OF PERMRTEE DATE
APPLICATION, PERMIT - ir�p P/C
DATE'S-""' f-) '""._7
NUMBER r p
ISSUE f TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
LA
SIDE ❑
PROPOSED USE /r " ".r, 7 /
NO. D EL. O. ✓' NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
c/)
Gamge/Carpon
WPatio/Deck
LL
PooVSpa
{ /
Z
Re -Roof
n
COmmeTC1at
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L
m
Valuation ADJ.AREA
QUANTITY
DESCRIPTION
FEE
J
II
W
z
Z
O)
J
a
U
Z
Q
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
t°
{/I
COMMENTS f';'9 4 f, le
i
RECPT. NO. PAID BY VALIDATION
WHITE--DepaRmenl Copy, YELLOW—Flnence Copy, PINK —Assessor Copy, GOLDENROD—Rle Copy, GREEN—Applicani's Copy