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Home My WebLink About09-007NEE UL1,110 D D'MiR i OL.L_ 1U w z 0 0 LU w 0 w a- w w rn Z O xd W Z 1U W Z Cn H O M J J t% J LU LU CI_ O cc d W F— rr W CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 Copley DXiye Diamond Bar, CA 91765 (909) 839-7020 Fax (909)461-3117 Building Inspection Hotline (909) 839-7027 BUILDING PERMIT APPLICATION /JOBSITE , ADDRESS � C l w A l iG; /YIli d ik, APN LOT TRACT OWNER % �1 t /y(t.. j 4 fr_ ADDRESS r-�:' O (17 &_-611,1 (61 J:l / CITY (7o Ufr ic- ZIP g[7 Z- TE( '203K 7-10 S j APPLICANT i 6hTEL.( - f CONTRACTOR - ADDRESS j CITY ZIP 5i/-;1,4/TE tL M L22-6-4ilk 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. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES APERMITTO 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- FESSIONS CODE) OR THATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THEALLEGED EXEMP- 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 ($500).): ❑ 1, AS OWNER OFTHE 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 ONEYEAR 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). ❑ 1, 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 PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE CONTRACTOR 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 BYSECTION 37000FTHE LABOR CODE, FORTHE 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 WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE OMPLETEDOFTHE PERMIT IS F0RONEM/l'DREDDCLtARS($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 SOAS TO BECOME SUBJECT TOTHE 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 COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE 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 STATE THAT THE ABOVE INFORMATIONTSB®BPECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILL CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE NAME (PRINT) //9 /0 y SIGNATURE OF PERMITT DATE PRESS FIRMLY � PPLICATIQN PERMIT P/C DATE ca NUMBER # tQ9 - CSi )77 IS LIE TYPE OCC DA E CONST. GROUP Z NING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE p c� PROPOSED USES NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck U Pool/Spa 0 Z Re -Roof 0 Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J a U cc F- U W J W (D Z_ m J a U_ Z Q U W CONSTRUCTION PLAN REVIEW \��J ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES MMENTS CPT. NO. PAID BY VALIDATION F- WHITE —Department Copy, YELLOW —Finance Copy, PI K—Assessor Copy, UULUtNHVU—hll8 GOpy, LiHttN—Appucant's L:opy