HomeMy WebLinkAbout16093 (34)a� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION,
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ADDRESS 10 30 M, &0& EA1 SpJC�iAT,q C a, E
APN LOT TRACT
OWNER�'rN•F A usSEU-
ADDRESS 1030 ►J S A- C () A-
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CITY P.T6—A A ZIP 9/ TEL.7/y ,ftf-d 176
APPLICAN TEL.
CONTRACTOR
ADDRESS -3 P-7-7 Ao if
CITY Ll4Jk5"- )IOC/ ZIP 7 1 L TEL. •
ARCFVENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERAUM THAT I AM EXEMPT FROM THE CONTRACTORS L -
CENSE LAW FOR THE FOLLOWING REASON (SEC. 70.71.E BUSINESS AND PROFESSIONS CODE: ANY CITY OR
N COUY WIICi REOLARESA PERMTTO CONSTRUCT,ALTER IMPROVE, DEMOUSH,OR REPAIR ANY STRUC-
IURE. 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 LN
CENSE LAW (CHAPTER I (COAMENCNG WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (OW).):
O L AS OWN CA
OFTHE PROPERTY.
OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILLDO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. TNa, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO
BUILDS OR IMPROVES THEREON. AND W40 DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH NS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFEREDAL FORSE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION, THE OWNER-0UNDER WILL HAVE THE BURDEN OF PROMO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 L AS OWNER OF THE PROPERTY. AM EXCLLISWLY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U-
DENSE LAW DOES NOT APPLY TO NW OWNER OF A PROPERTY M40 BUILDS OR IMPROVES THEREON AND
WHO
CONTRACTS FOR SUCH PROJECTS WITH A OONTRACTORIS) LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
O 1 AM EXEMPT UNDER SEC. B. I P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESYAFFIIM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FORCE -EAND EFFECT.
LICENSE CLASS `A C, LIC. NO. 59 Z
DATE �:9 CONTRACTOR A I I
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I PAVE AND YPLL MAINTAIN A CERTIFICATE OF CONSENT TO SELFHNSURE FOR WORKERS'
VD COMPENSATON. AS PROED BY SECTION 5700 OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
-1 HAVE AND WILLMA,YRAN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION
37DO OF THE LABOR CCOE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15
ISSUED. MY WOR(ERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER �Cy"h+�-CS -J_,y
POLICYNIMBER . / rL,r0 D
(THIS SECTION NEED NOT SECOMP ETEDOFTHEPOWfT 6 PoRCNE HUr•LREDOCILLAAS RIO%OR LW']
ICERTIFY THAT N ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMTIS ISSUED, 1
{ SHALL NOT EMPLOY ANY PERSON ]MANY MANNER SO AS TO BECOME SUBJECT TO THE
j WORKERS'COMPENSATON LAWS OF CALIFORNIA, AND ACRE E THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
� fXD I FORTNMM COMPLY WITH TIO".,E,�RONSIONNS�
{�
I GATT: �' �� APPLICANT
WARNIN . FAJ URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRM:NAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ISI00.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROYIDED FOR N
i BECTION 07060E THE LABOR CODE. INTEREST. AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
i
1HE THE ERFO MANCE PENALTY OFPERJURY THAT THERE ISACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 70N7, CV. C.I.
I
LENDER'S NAME
LENDERSADORESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT ME ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CrTYANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCT ON. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERM EE NAME (PRINt) „� -z /
IP
G SIGNATURE OF PERAOTTEE DAIE
PRESS
FIRMLY
APPLICATION
b PERMIT P/C
DATE
/ NUMBER
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ISSUE
.TYPE
OCC
DATE
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CONST.
GROUP
ZONING SETBACKS
FRONT RW
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REAR
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SIDE/SIDE STREET RW
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SIDE
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PROPOSED USE
NO. DWEL
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
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MID HT. BOND-$EAM
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IFRAMINGNENTILIATION
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FINAL:BOND BEAM
IROOFCOVER
PRE -GRADING -
-
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IROUGH HEATING' -
BENCHING
[ROUGH ELECTRIC.--...
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ROUGH GRADING
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FINISH GRADING
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POOL'ELECTRIC
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POOLIFENCING
WALL -INSULATION -
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POOL'FINAL
[CEILING INSULATION
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OFF SITE IMPS.
'DRYWALL NAILING
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DEDICATIONS
;SEWER - .....
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FINAL'EPJG.'
;SEPTIC TANK
LANDSCAPE/IRRIG.
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;SEEP_ PITILL. _ _
ON SITE IMPS.
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FINALZONING
FINAL CONST,
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FIRE DEPT. FINAL
;FINAL. HEATING_ .. - .I
HEALTH DEPT. FINAL
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