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Home My WebLink About9543 - 3333 BREA CANYON RDCITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT 21660 E. Copley Drive Suite 190 909) 860.3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION 1 ADDRESS *-'L ?i JJWA CWYal ROW APN LOT ACT OWNER ADDRESS O CITY ZI -TEL APPLICANT TEL ' CONTRACTORS ADDR SS CITY ZIP TE ARCRENGI ( DESIGNER All ADDRESS CITY ZI TEL 1[e1 g OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE COIURACTORS LF CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.5 BUSNESSAND PRDFESSIONS CODE ANY CUYOR COU IM M41CH REOUIRESA PERMITTO CCNSTRUCT,ALTEF4 WPROVE, DEMOUSKCA REPMRANYSTRUJG TIME, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE R LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (CHAPTER s MCMMENCMM WITH SECTION Yam) OF DIVISION S OF THE BUSINESS AND PRO. FESSON3 CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500)k O L A$OWNER OFTHE PROPERTY, OR MY EMPLOYEES MATH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, ANO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7041, "1- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTYVNO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WOR( HIMSELF OR HERSELF OR THROUGH HIS 09 HER O'MF EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFTEREDFORSALE IF.HOWEVER THE BUILDING OR AUPROVEMENT IS SOLD INTMNONEYEAROFODMPLE- TIN, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF MEL O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS tl- CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY W40 BUILDS OR IMPROVES THEREON. AND WHOCONTRACTS FOR SUCH PROJECTS NTH ACONTRACTOKS) LICENSED PURSUANT TO THE OONTRAG TORS LICENSE LAW). O 1 AM EXEMPT UNDER SEG B. A PC FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AAL LICENSED UNDER PROVISIONS OF CHAPTER e (OOMMENCNO MAIN SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FURL FORCE EFFECT. n LICENSE SS44o„' - "LIC - NO- I DATE T CCNr MCTOR . WORKERS! COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND VMLMANTAN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR YORKERS' 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 WALL MAINTAIN WORKERS COMPENSATION INSURANCE. AS REOUIRED BY SECTION 3700 OF THE LABOR OWE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. W ERS' COIAPENSATXN INSURANCE CARRIER POLICY NUMBER ARE CARRIER "'^ 1 n DP (f7 y - POLICY NUMBER DSS MOM NETDNDTBE OOMPLETEDOFTHE PERMIT 0 FORCrEHUNDRED DOLI/VLR MOMOR LESSI 1 CERTIFY THAT N THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOTEMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME SUBJECT M THE WORKERS' COMPENSATION PP W SXWS 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 SIRUECTAN EMPLOYER TO CRIMINAL PENALTIES AND CNx FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($I00,000). INADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 37% OF ME 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 OF THE YORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3W. CN. G). LENDERS NAME LENDER'S ADDRESS 1 CERTIFY THAT I HAVE READTHIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE M OOMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULDINQ CONSTRUCTION. AND HEREBYAUT/ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES. LJnelce bac eG PERMUTE (PRINT) OfPERMITTEE DATE PRESS FIRMLY APPLICATION 116( Lj PERMIT qDATELLNUMBER 0PIC N ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW REAR O SIDEISIDE STREET RWLjSIDE PROPOSED USE. IU,5 OM XjjaEQM(= ONC[6T RdC1F NO. DWEL NO., NO, UNITS STORIES ' BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREANALUATION SFFVADO/REM CO GeragararpW WPatlolDeck V- PooVSpa ZRe Rod Commercial m Valuation ADJ.AREA OUANTITY DESCRIPTION FEE JQU WJW Z m J a U_ Q2 2U CONSTRUCTION PLAN REVIEW it art ELECTRIC PLUMBING h MECHANICAL INSPECTION FEE Dr ISSUANCE SMTP ENERGY PIC ENERGY PERMIT t.i 03RETENTIONFEE: OCT^ Y+ I 1 D PRE -ALT FEE: CITY nt= n1AVQiya BAH 131Ill mimn wmn SAFETY TOTAL FEES C ME L 2 iali RECPT. 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