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Home My WebLink About24030DIVIONNIZA t i ' CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY &z DEVELOPMENT SERVICE5 21825 Copley Drive, Diamond Bar, CA 91765 % RESS' 7027 (909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-FIRMLY BUILDING PERMIT APPLICATION o ADDRESS 60�IVSl °.° APN LOT 3q TRACT �p OWNER ` ILL_ ADDRESS C w ZIP TEL. Z CITY "� t! O 0 APPLICANT TEL. zi CONTRACTOR AC AMA9S ADDRESS O CITY ZIP TEL. w ARCH/ENG/ z DESIGNER a ADDRESS '9- P 5 CITY ��L— ZIP TEL��I.6515.EM to OWNER -BUILDER DECLARATION O I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS - W CENSE LAW FOR THE FOLLOWING REASON(SEC.7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR UZ COUNTY WHICH REQUIRES A PERALITTO CONSTRUCT ALTER ,IlAPROVE,DEl,LOLISH,ORREPAIRANYSTRUC- W TORE, 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- 0, FESSIONS CODE) ORTHATHESHE ISEXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- U TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($600).): O ❑I, AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITHWAGES AS THEIR SOLE COMPENSATION, Z 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 W OFFFERED FOR SALE IF HOWEVER,THEBUGH HIS OR HER OWN ILDING OR IMPROVEMENT IS SOLD HNONEYEAROFCOMPLPROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR Z IMPROVE FOR THE PURPOSE OF SALE). LICENSED W❑I,AS OWNEROFTHE PROPERTY, AM EXCLUSNELY CONTRACTING WITHE:THE CONTRACTORS LI- CC i0 CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- W CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTOTHECONTRAC- TORS LICENSE LAW.). O O 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON LL Z O �5 OO W U7 U) 0 Q W tR in Q 0 W Z O w ILL. J W CL d W �i W d Z C1 J_ M CO Q S DATE OWNER LICENSED CONTRACTORS DECLARATION PROVISIONSI HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER C 9 (COMMENCING WITH SECTION 70oo) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, ANDR MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS 6 J LIC. NO. _ A(� DATE CONTRACTOtI"f t w `W_ WORKERS' COMPENSATION DECLARATIO 7YAFFIRM 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 3700 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 eY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' OOMPEN_ SAT1ON INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER f��Jl A7 1�^I`��►b C POLICY NUMBER (THIS SECTION NEED NOT RE OC&IFLETED OF THE PERMIT IS FOR ONE K94DRED DOLLARS ($100)ORLE64 I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS 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: � is APPLICANT: �pONIG�� WARNING: FAILURE TO SECURE WORKERS'COMPENSATK)N COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONEH NDRED THOUSANDS DOLLARS 3OO $1 �HE LABOR ADDITION TO, THE INTEREST, AND ATTORNEYSFEEA (AGES AS PROVIDED FOR IN SECTIO CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A NSTRUCTION LENDING ENCY FOR THE PERFORMANCE OFTH 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 THATTHEABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION ONST ON PROPERTYFORI UCTIAND AUTHORIZE NPER REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE w APPLICATION PERMIT P/C # DATE ISSUE NUMBER TYPE OCC DATE CONST. GROUP ZONING SETBACKS RW 0 FRONT REAR 0 SIDE/SIDE STREET RW SIDE Sr- PROPOSED USE NO. DWEL. UNITS NO. NO, STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFRIADD/REM Garage/Carport C0 WW Patio/Deck U- Pool/Spa ZRe -Roof ® Commercial m Valuation ® ADJ.AREA QUANTITY DESCRIPTION FEE Q . CON. I . IIyM� AWC U4. n+- 1'0+ 1 25 Yrw" 1 fir' W -2n CAW Le `+ clot t (D IV =1N1� l i1 4. 2 "1Vf3L 11� ISO} F,�P�tF1Cg=gyp 2 �+p 6 w4rA �i9 I U W�Iz. tAwk I bj a n^ w �:3 V 2 �, J�►1 ��T.r -y �y CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE OO•�� ISSUANCE SMIP ENERGY P/C ENERGY PERMIT YO e RETENTION FEE: PRE-ALT FEE: Coov. YELLOW— inane Copy, TOTAL FEES COMMENTS RECPT.NO `� � I�� PAID BY —Assessor Copy, GOLDENROD —Elie Copy, C ------------- �✓ VALIDATION Copy