HomeMy WebLinkAbout16044 - 23617 GOLDEN SPRINGS DR1 _ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
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BUILDING PERMIT APPLICATION
JOBSITE
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CITY 1�_ ZIP 9 7& EL.907-1`16/41I�
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC.7D31.5 BUSINESS AND PROFESSIONS CODE: ANYCITY OR
COUNTY WHICH REQUIRESAPERMITTO 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 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 APPLICANTTO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
❑ LAS 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 THEBUILDING OR IMPROVEMENT IS SOLD WFHINONEYEAR OFOOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FORTHE PURPOSE OF HAVE
❑ I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70H, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANTTOTHE CONTRAC-
TORS UCENSE LAW).
❑ 1 AM EXEMPT UNDER SEC. B. & PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM 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.
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LICENSE CLASS � M LIC. NO. J ��
DATE ! O Za CONTRACTOR
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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 37W 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
3701) OF THE LABOR CODE. FOR THE PERFORMANCE OF THE'rVORK FOR WHICH THIS PERMIT IS
ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER A-- 4>
POLICYNUMBER L" j & P
(TH ISSEOWN NEED NOTBE COMPLETED OFTHE PERMIT S FOR ONE REARED DOLLARS Wool ORLESS),
I CERTIFYTHAT 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 SUB JECTTO THE
WORKERS' COMPENSATION LAWS OF CAUFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECTTO THE WORKERS' COMPENSATON PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHA FORTHWITH COMPLY WITH THOSE OVISION3.
I DATE: APPLICANT:
1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND
DOLLARS (6100000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
i
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.).
1
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATKIN IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
JCONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVEWENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PRESS
FIRMLY
APPLICATION �PERMIT �r\ P/C
DATE NUMBER U If
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SQ. FT.
FACTOR PSF
ADJ. AREAIVALUATION
SFR/ADDlREM
W
Garage/Carport
W
Patio/Deck
Pool/Spa
Z
Re -Root
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Commercial
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Valuation ADJ.AREA
QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING CIAf 0 U
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP _
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
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CITY �7�p'TD1I��TMO RA'R
TOTAL FEES
COMMENTS
RECPT NO. PAID BY VALIDATION
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