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Home My WebLink About26443in J J lL J CC W d O CC d Z W I -- cc W a- C7 Z CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 Copley Drive, Diamond Bar, CA 91765 (909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027 PRESS 's BUILDING PERMIT APPLICATION FIRMLY JOBSITE (� a ADDRESS C( APN LOT TRACT OWNER ��V-�tili� P(--9 e ADDRESS %n D CITY _b4: fLw)UJ ZIP —ZIP 9176 TEL. APPLICANT TEL. CONTRACTOR WK ADDRESS MCa A QQ CITY \ 1nIVic)r ZIP _9 TEL. `YHZ07171`�/ 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 REPAIR ANY 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- FESSK)NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): ❑ I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAROF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION VYLICENSE AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER NCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND IS IN FULL FORCE AND EFFECT. [� h LICENSES CLASS LIC. NO. DATE '-`j.-j CONTRACTOR IA$CC - 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' COMPENSATION, AS PROVIDED BY SECTION 37GO 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 S' /WORKERCOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER -AIC4 POLICY NUMBER_ e3a A (THIS SECTION NEED NOT BE COMPLETEDOF THE PERMIT IS FORONE HUNDREDDOUARS($100)ORLESS� 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, ANDATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OFTHE 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 STATETHAT 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. + � Aact C� 1INkr PFPWTTEE NAAE (PRINT) 1 „ ) (� pay/ Al c9 /� 21 �I(,C1/'� //- / / SIG NA FPERMITTEE -b E APPLICATION ry �3 �� DATE L �"; (l' ISSUE / DATE Y �� / /� PERMIT P/C NUMBER c # TYPE OCC CONST GROUP ZONING SETBACKS FRONT REAR SIDE/SIDE STREET SIDE RW RW ❑ ❑ ❑ ❑ PROPOSED USE jk3 ()ezz,A (,[I NO. DWEL, NO, UNITS STORIES (�', (®e NO. BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck LL Pool/Spa 0 Z Re -Roo( ® Commercial E5 m Valuation t r ADJ.AREA QUANTITY DESCRIPTION FEE J Q U N U W J W 0 Z m CONSTRUCTION } PLAN REVIEW 13 , ELECTRIC O PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: Z b -ems TOTAL FEES1�11L�� COMMENTS '3®• `G RECPT. NO. PAID BY VALIDATION H I. WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy