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Home My WebLink About18429 CITY OF DIAMOND BAR ��'�'� �� 'l,��'-- ��- ��`` DEPARTNIENT OF CONDvIUNITY&DEVELOPMENT SERVICFS ,' 21825 E.Copley Drive "� �9o9>sdo-3i9sF��9o9>86i-3ii� � PRESS BUILDING PERMIT APPLIGATION � FIRMLY � JOBSITE APPLICATION PERMIT P/C �7 o ADDRESS��ZCS �YTY/I,�N ��GL �� DATE � �� 2'NUMBER # �G" IS L � ISSUE /� TYPE OCC r APN LOT TRACT___ DATE "�+ CONST. GROUP p OWNER _1►2I�. �UIR�_ � LL ADDRESS ZONING SETBACKS z CIT`( ZIP TEL. � � FRONT RW ❑ �j APPLICANT �� EL:�J TEL. S{DElSfDE STREET RW ❑ m CONTRACTOR {- C- �'�'. - �` SIDE _ Q � ADDRESS�� 7 ��• ( 'C'�"`-' �-� � ��' PROPOSED USE KI�'41 EN EX,TEAJ��N o CITY �-' �� '0-``J ZIPr_�� TEL. ?C��[�� w ARCH/ENG/ z DESIGNER ��A NO.DWEL. NO. /1 NO. /Li a ADDRESS P.�+ _ , �► �� UNITS STORIES BEDROOMS � CITY �J ZIP_�1 TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM Q I HEREBY AFFIRM UNDEfl FENAL7V OF PERJUflV THAT I AA1 E%EMPT FROM THE CONTRACTORS LI- Gfl18gE/CdfPOrt W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31.6BUSINESSANDPROFESSIONSCODE:ANYCITYOfl ((� U COUNTVWHICHREQUIRESAPEFMITTOCONSTPUCT,ALTEft.IMPROVE,DEMOLISH,ORREPAIRANVSTPUC- W Pd�10/DBCIC w TURE,PRIOF TO ITS ISSUANCE,ALSO REQUIRES THE APPUCANT FOfl SUGM PERMIT TO FlLE A SIGNED w STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PFiOY1510NS OF THE CONTRACTORS ll- � CENSE LAW(CHAPTEF 9(COMMENCING WITM SECTION 7000)OF DIVISION 3 OF THE BL'SINE55 AN�PRO� � POOUSPB O FESSIONSCODEJOFTMATHEOfl5HEI5E%EMPTTHEREFROMAN�THEBASISFORT LEGEDEXEMP� (� U TION.MlY V70lATION OF SECTION 7a31.5 BY ANV APPLICAM FOfl APERMIT SUBJ 1HE APPLICANi i0 Z Re-Root � A qVll PENALTV OF NOT MORE THAN FNE HUNOFEO DOLLARS(5500).)� � ❑I.ASOWNEROFTHEPROPERTV,ORMYEMPIOVEESWITHWAG THEIRSOLECOMPENSATION. � COf11ff10fC18I Z WILL�O THE WORK,AND THE S7RUCTURE IS NOT INTEN�ED OR ERED FOR SALE(SEC.]044,BU51- J � NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENS W DOES NOT APPLY'O AN OWNEfl OF ? PROPEHTY WHO BUILAS OR IMPFOVES THEREON,AN� OES SUGH WORKMIMSELF OR MERSE�f aR m (t THROUGHHISORHEROWNEMPLOYEES,PPOVIDED TSUCHIMPROVEMENTSARENOTINTENDEDOF QOFFEREDFORSALE.IF,MOWEVER.h1EBUILDING MPROVEMENTISSOLDWiTHINONEYEAROFCOMPLE- Z TION,TME OWNER-BUILDER W1LL HAYE TH RDEN OF PROVING SHAT HE OFi SNE L11D NOT BUILD OP � IMPROVEFOHTHEPURPOSEOFSAIEf. w ❑I,ASOWNEFOFTHEPROPE ,AMEXCLUSNEIVCONTRACTINGWIT4LICENSE�CONTRACTORS — � TO CANSTRUCT THE PROJECT C.7044.BUSINESS AN�PROFESSIONS CODE'.THE CONTRACTORS LI- Vdl{18SIOf1 � �'� ADJ.AREA W CENSEIAWDOESNOTAPP OANOWNEROFAPROPERTVWNOBUIL�SORIMPROVESTHEREON,AND � WHOCONTflACTSFOR PROJECTSWITNACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPT40N FEE TORS IICENSE LAW � J O ❑IAM MPTUNDERSEC. 9.8P.G.FORTHISREASON � � — � � p OWNER U Z W � LICENSED CON7AACTORS DECLARATION W Q � IHEREBVAFFIRMUNDERPENALTYOFPERJURVTI-.ATIAMLICENSEDUNDERPROVISIONSOFCHAPTEF � d 9(COMMENCING WITH SECTION�000)OF DIVISION 3 OF THE BUSMESSANO PROFESSIONS CODE,AVD Z 'X MV LICENSE IS IN FVLL FOflCE AND EFFECT._, m �ic ( � � LICENSE LIASS�`�LIC.NO.� � ` J V DATE ��/��,TT�—� CONTRAC70F h�V�'��U� (1 �'� �- W d� WORKERS'COMPENSATION DECLARATION -� Q � U � I HEREBY AFFIAM UNDEF PENAI.TY OF PERJURY ONEOF T14E FOILOWIfIG�ECLARATIONS: Z Q � IHAV WIILMAINTAINAC 'ATEOFCONSENTTOSELF-INSUR � WORKERS' 2 QEN TION.AS PRO D BV SE ON 3]0o OF THE lAB ,FOR THE PERFORMANCE W THE W RK FOR THIS PERMIT I D. � 0 � / ///�� w .�.LL�AVEANOWILLMAINTAINWORKERS'COMPENSATIONINSURANCE.ASREOUIREDBVSECTION �j Q 370oOF THE LABOR CODE,FOR THE�EftFORMANCE OF THE WORK FOR WHICHTHIS PERMIT IS I �l �� ISSUED.MV WORKERS' FNSATION INSURANCE�6AfilER AND POU V NUMBEAARE: CONSTRUCTION _�_ �� caaaiea�l�� %' �l-'�� PLANREVIEW _. O POUCV NUMBER C�--I.�'"��Z.- L--'C�i�7� = — ELECTRIC z 4 � (i}iIS5Ec7%7NNEmNO7BE00MPLEfEDOFTHEPEf�1Mt5FOR�NEHUpqFEDDOLLMS(E1[a10RLE551. PLUMBING w MECHANiCAL Z I CERTIFY THAT IN THE 7ERFORMANCE OF THE WORK FOR W N THIS PEFMIT IS ISSUE�,I (} SHALL NOT EMPLOY ANV PERSON IN 1NV MANNEF AS T E�AME S .-CTTO THE INSPECTION FEE � WORKEFiS'COMPENSATIONLAWSOFCALIfORNtA,A ' REETHAT . OULDBEGOME - SUBJECTTO THE WORKERS'GOMPENSATION PROV S OF SE N 31aa OF THE LABOR � COD ISH LFORTHWITHGOMPLYWITHY.OS VI � NGE .._ �� O . � �...�- �. SMIP �, ;/-( L p DATE: APPLICANi� ' �• J / �" ENERGY P/C J WARNING:FAILURETO SECVRE WOfiKERS'CO NSATION CWERAGE IS UNLAWFUL,AND SMALLBE � SU&IECTAN EMPLOY[R 10 CRIMINAL PENAt,T S�tl CIVIL FlNES UP TOONE NUN�RED THOUSANO ENERGY PERMIT -. DOLURS(5190,000),IN AD�I�ION TO THE CO O GOMPENSATIDN,DPMAGES AS PftOV4�EU FOR IN J SEGTION3]OBOFTHELABOflGODE,INTER�ST,ANDATIORNEY'$FEES. RETENTIONFEE: . � w CONS7RUCTION LENDING AGENCV PRE-ALT FEE: � O � IHEREBYAFFIRMUNOERP�NALTY�F PERlVRYTHATTHERE150.CG"1STRUGTION�EN�INGAGENGY _. __ ._.,,.— � FOR THF PFRFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3J9],GIV.G.). z W � LENOER'S NAME F- IENCJER'SA�DRESS -� ��--- ()� � � f CERTIFY THAT 1 HAVE REA�THIS APPUCATION ANO STATE THAT 1HE A80VE INFORMATION IS G�fiflEGT. TOTAL F EES j `+" "�� W 1ACPEETOCOMPLVWITHALLCITYAN�COUN7VORDINANCESANDSTATELAWSRELATINGTO9UIL�ING � CONSTqUCTION,AND HEREBYAUTHORRE REPRESENTATNES OFTHIS GOUN�V 10 ENTER UPON THE � AHOVE�MENTCNJEDPflOPERTYFORINSPECTIONPURPO5E5. Z COM ENTS .... � ��l''�-�� 1�4iZ L9..� �P1"2�c7 �.� J 1 � 3� Pb m PERMI77EENAME(PRINT) n- � � �"V � SIGNATUREOFPERMITTFF DAiE RECPT.�O. P�Td Y VALIDATION x ~ WH17E—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GflE N—Applicaofs Gopy t.�� :'��^,�F�.� :i �^ i�3 ;��a Y,�� i� n� '� �a� .i�t.=t at� �� a ,� '_� � �� . � , . . . .��,i .�' -� , , ��"�. �S ,�-//6�- :�. l : - -o�- , �v�� .�� _ _ �- �� - _ �r-��Y �� c� , _ ,�� " ��' � _ _ . / �� : �� , _ � % _ ; r�:�� . �, _ _ �J° �' _ �� i��=� � ,�oK � �� o �, � � � � � �,�� C ��d� ��/ f�� ,� . �� _ __ _ �� .e ,.: � _ _ � _ ,�� , �� , �� q"� � ��„ ,� ��,s:� 4 ; , „ � � � _ . � � ,� � °� _�� a�� - �� a �� .,, _ _ _ . � 1� � �� E'' � .� :n� � �� a � �;, ° � a �'� � i �� _ _� k a � �, � � � �, _ _ —� �: av �,�� .e �� , � �: t �� _ s � '9 ` � " 6 . . ... . . . ... .. . .. . . . .. . . .. . .. . . ... ... �` �� E 3 � g � . . . . .. . � r. _ � .� ,�.� v i�., _. ..._. ... .... ... . CITY OF DIAMOND BAR �� DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE �� N �� ADDRESS �� APN LOT TRACT OWNER MR«/s/��U�R.� ADDRESS CITY Z I P TEL. � APPLICANT TEL. CONTRACTOR'}-c >�__"E ADDRESS�' �7(-r�'�,� L+�-�(�+ CITY�= o�; L rl.-r J ZIP� ��TEL ?�C� ��c(� �f ARCH/ENG/ DESIGNER Yr�J�I�fa ADDRESS P.'+ CITY IJ ZIP-�1 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 BUSIN ESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUGT,ALTER. IMPROVE,DEMOLISH,OR REPAIR ANV 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 SHEIS EXEMPT THEREFROM AND THE BASIS FORT LEGED EXEMP� TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FORAPERMIT SUBJ THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): ^I,AS OWNER OFTHE PROPERTY,OR MY EMPLOYEES WITH WAG THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR EKED FOR SALE(SEC. 7046, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENS W DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND OES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED TSUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF,HOWEVER.THE BUILDING MPROVEMENTIS SOLD WITHIN ONE YEAROFCOMPLE- TION,THE OWNER-BUILDER WILL HAVE TH RDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^I,AS OWNER OF THE PROPE,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT C. 7044,BUSINESS AND PROFESSIONS CODE'.THE CONTRACTORS LI- CENSE LAW DOES NOT APP OAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FORS PROJECTS WITH ACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAC- TORS LICENSE LAW ^I AM MPT UNDER SEC. B. &P.C. FOR THIS REASON D 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- 3 LICENSE CLA LIC. N0. I S S f DATE��' '� -�CONTRACTOR X�Vc��L;l(� �� WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 I HAV WILL MAINTAIN AC CATE OF CONSENT TO SELF-INSUR WORKERS' EN TION,AS PRO D BY SE � ''�lON 37000E THE LAB ODE,FOR THE PERFORMANCE THEW RK FOR H THIS PERMIT ISIGS� ) �+.LkLAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MV WORKERS' ENSATION INSURANCE$',AFRIEfI AND POLL V NUMBER ARE: �,C� II� �Z� CARRIER �� aI POLICY NUMBER�� -L-�-%��,� (THIS SECTION NEED N07 BE ODMPLETED OF THE PERMR IS FOR ONE HUppRED OCLLAGiS(5100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W H THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PERSON IN ANV MANNER AST ECOME S CT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,A REE THAT OULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROV S OF SE N 3700 OF THE LABOR H FORTHWITH COMPLY WITH Y.OS VI COD I S c � � � DATE: -APPLICANTi WARNING FAILURE TO SECURE WORKERS'CO ATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALT S tl CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000), iN ADDITION TO THE CO 0 COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTERJiST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACGNSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CI V.C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. �i�J T„��I,��kl PERMITTEE NAME(PRINT) SIGNATURE OF PERMITTEE DATE WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy %'�v�� ;CYO