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HomeMy WebLinkAbout15720U111M1111 Ing ilp CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY TE ADDRESS 2�Bp �IGIjC �%v11�/ Dg APN LOT TRACT _.S'I OWNER 4&V& Vh5>2- ADDRESS / CITY ZIP 91' EL. APPLICANT TEL. CONTRACTOR ADDRESS Oone— CITY ZIP 9/7TUD TEL,' Z 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. 7WL S BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REDUIRESAPERIATTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 a (COMMENCING WITH SECTION 7W0) 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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): p I, AS 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_ F.HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ I, AS OWNER OF THE PROPERTY, AN EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CCNTRAC70RS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). U IAM EXEMPT UNDER SEC. _8, A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT LAM LICENSED UNDER PROVISIONS OF CHAPTER 6 tCOMMENCINO WITH SECTION 70001 OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLASS �• 36 LIC. NO. iz 3,S'z DATE 6. 1� 10 Z CONTRACTOR R WORKERS' COMPENSATION DECLARATION 1 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 WOO OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. -I HAVE AND WILL MAINTAIN WORKERSCOMPENSATION INSURANCE, AS REOUIR ED BY SEC -ION 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 NE® NOT BE OCMPLETEOOFTHE PERMIT IS FOR ONE HUNDRED UJU AR4 ($10)) OR LESS). 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 TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE. 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: _ APPLICANT WARNINGFAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,0W). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.). LENDER'SNAME LENDERSADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY Wift ALL CITY COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND E EBYAUTHO IZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTK)NEO P O RTY FOR I PECTION PURPOSES. PERMITTEE N PRINT) L SIGNATURE OF PERMITTE ATE APPLICATION . PERMIT P/C DATE 00 NUMBER M ISSUE r �O TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW n REAR SIDEISIDE STREET RW SIDE ❑ ❑ ❑ p 1 PROPOSED USE v NO. DWEL. NO. UNITS l STORIES NO. BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD(REM to Garage/Carport W Patio/Deck IRLL Pool/Spa V Z Re -Roos 0 Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE /i R-'PIS z wAZ-s U Z 2-.aRB & Di s 8 AS A � ✓ U. / L CoNN��-G io CONSTRUCTION PLAN REVIEW 'ELECTRIC LUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: _ , _— - / _ TOTAL FEES COMMENTS (QO (, 30 RECPT NO. It PAID BY VALIDATION WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy ..5 -/ 1" j SET R.At X FLOOR JOIST NA REQMTS �I$I. ROUND UNDER FLOOR DUC-1 _ r jl`a E, tl 3 UNDER FLOOR CONDUIT ._ Ss A r A " FIRFPLACE FOUNDATION 1`"P4' _ FIREPLACE BONDFAIU1 _._ BOND. i MID HT. BOND BEAM ,NAT � R . i 1 F c- _ HOOF- R Alrii €3 . BOND BEAM _ F r°AtOING,W.-°O, H IC E ON, FINAL BOND BEAM >: 1001 ... L E PR GRADING POOCH EI ECTRK- � �ROUGH C P D`NG FINISH GRADING POOL ELECTRICI 1 �t A��>z }I£'*.g t[� Q.. .... i:,J !"N�v1N k — POOL FINAL .. OFF SITE IMPS. DEDICATIONS ;N A L Nta SC ee RANK ,?iCiSvAF �!Cti-+Et'.�. ZOO! F`NIAI CONS7 �€RE ()r 'T F!NAL %F i r+ SIC 3 DE"'T F A F .L P(ii <` _I r. ��ly pg � �, ) �� � � _� �:-11����'� S P ., . -TANK SIZE' W:2 O IULj LL J LL O CC d Z W a d Z 0 m a 2 1-- 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 JOBSITE ADDRESS APN LOT-1 TRACT OWNER /T)I "t.1. ] ate ADDRTS} e°I(i . `, "-��!'�r-!' � l � t-lr CITY i ,64 i'_ZIP `�' t,:STELAEt� (c't L1-1 APPLICANT TEL. CONTRACTOR O t� 1 i'�' .� t ADDR Sri.�. CITY. —tea. V \t��' ZIP LI (1 �t {�E�4 t ARCH/ENG/ DESIGNER1iL�A—iC 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. 7031.6 BUSINESS AND PROFESSIONS CODE: AINY CITY OR COUNTY WHICH REOUWESA PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 TODO) 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- TKIN. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (fSM).)- U I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSP 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 15 SOLD WITHIN ONE YEAR 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). ❑ I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC, 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LF CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). O I AM EXEMPT UNDER SEC. B. 6 P.C. 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 7") OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE L ASS -' LIGNO CO. ` e�� r DATE 4 � � tI � CONTRACTOR T` f�-- 1 ' R WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERUURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3TDD 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 3700 OFTHE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY10'L)R(ERRS' GOMrSAT� 5ARRIFR AND POLICY NUMBER ARE. CARRIER /_- I POLICY NUMBER (THISSECTION NEED NOT BE CCAFLETEDOF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($1D0)OR LESS} 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN ANY MANNERS AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATON 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 WORKERSCOMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (11100."), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 30ST CIV C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITYAND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE.MENTKNNED PROPERTY FOR INSPECTION PURPOSES. PERMITTE N OW� ^L� �411_ 1 1 ( \ ` C L SIGNATURE OF DATE PRESS FIRMLY APPLICATION DATE 1 � PERMIT P/C NUMBER I # ISSUE TYPE OCC DATE f%��w CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ S SIDE/SIDE STREET RW ❑ 1 SIDE Cl PROPOSED USE `? NO. DWEL. ++ NO. NO. r+) UNITS f STORIES BEDROOMS i DE§gRIPTION SO. FT. FACTOR PSF ADJ. AREAVALUATION SVVADDIREM co Garage/Carport 2 Q6 WPatio/Deck - v_TO LL PoDI/Spa 0 Z Re -Roof Commercial m Valuation ADJ.AREA QUANTITY DESCR TION FEE J Q U cc U w J W t7 Z_ m a Q U_ Z Q 2 LU W Q CONSTRUCTION PLAN REVIEW ELECTRIC / w5v__' PLUMBING MECHANICAL INSPECTION FEE ISSUANCE AL.I(J SMIP i ENERGY P/C ENERGY PERMIT RETENTION FEE: - f~ PR - T TOTAL FEES LIFO/ry J� COMMENTS RECPT NO. PAID BY VALIDATION 1 J WHITE —Department Copy, YELLOW --Finance Copy, PINK—Asse§' cn o`py, GOLDENROD --File Copy, GREEN —Applicant's Copy r3 CITY OF DIAMOND BAR INSPECTION RECORD s F 73 A c K Fl U TC NDF IDATION M N D R' i, 1-30ND BEAM I cyz, ;'COF j �T T BE, 'N' 3f 'iRADNC, z EN G NC L-A-A- 44 XP,- (7 te- CD .12--,7t7�00 PC�f-rO V, KALL Ak---, !` CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 PRESS ,•. BUILDING PERMIT APPLICATION I FIRMLY JOBSITE ADDRESS APN LOT TRACT OWNER L I�> Y) a t G1 ','% ADDRESS I A 4-5 � K CITY fllZIP TEL'')O 1' APPLICANT CONTRACTORc.— ADDRESS —7 �l Sa k �t8fy Av 2 CITY C k m a -. rL ZIP TEL 5 ARCWENG/ 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 FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESA PERMIT TO 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 PROVI5IONS OF THE CONTRACTORS Ll� CENSE LAW (CHAPTER Y (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM ANDTHE BASIS FOR THEALLEGED EXEMP• TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3500).): ❑ I,AS 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 PROFESSK)IS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, 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 ONE YEAR OF OOMPLE TON, THE OWNER43UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPDSE OF SALE). O I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACDNTRACTORJS) LICENSED PURSUANT TOTHE CONTRAC• TORS LICENSE LAW.). D 1 AM EXEMPT UNDER SEC. B. L P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER P (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CUSS 2.c LIC.NO. DATEONTRACTOR I WORKERS'COMPENSATION•DEC SAT 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF•�HE FOU.dWI DECLARATIONS: _I HAVEAND WILL MAINTAIN A CERTIFIGTE OF ,$ T TO S F-INSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LA R 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 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. MY WORKERS' G0MPENSATII Iy�S 81A E CARRIER AND }POLICY NUMBER ARE1 CARRIER � l GO.. Yip/ /�^ /�� �4�� •���1 POLICY NUMBER _ /7 � L! (-� L 6 4V S .S (THIS SECTON NEED NOT BEOOMPLETED OFTHE PERMIT IS FOR ONE FU DRED DOLLARS ($1W) OR LESS} I CERTI FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS COMPENSATION LAWS OF CAL FORN7 D AG E THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATIONPRO IONS SECT ON 3]00 DF LABOP COD . I BHA' ORTHWITH COMPLY WITH THOSE PAOVIS S DATE: 2 2 JGI APPLICANT: WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COV AGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FIN UP TOONE HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TOTHE CO OF COMP.ENSA , DAMAGES AS PROVIDED FOR IN SECTION 310E OF THE LABOR CODE. INTERrTF AND ATTORNE FEES. CONSTRUC�OJiYLENDI G AGENCY I 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.). LENDER'S NAME _ LENDER'SAODRESS ICE IFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 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 ABOVEMENHONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE NAM EftPRINT SIGNATURE P M&I7 DATE APPLICATION PERMIT / P/ DATE NUMBER # ISSUE J i TYPE E'— C DATE CONST. GROUP ZONING SETBACKS FRONT RW Q _ REAR L] ❑ SIDE/SIDE STREET RW ❑ SIDE Q PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFRJADD/REM 0 Garage/Carport WPatio/Deck PooUSpa Z Re -Roof 0 Commercial m Valuation ADJ.AREA __ QUANTITY DESCRIPTION FEE J Q U 2 H- U w LU w C7 Z_ m ZD ZD a < % IA iJ d°G60 CJ w —V5 S a C+V" b C_ 3-fin�. CONSTRUCTION PLAN REVIEW _ ELECTRIC PLUMBING MECHANICAL INSPECTION FEE r• ISSUANCE _ ____• SMIP ENERGY P/C _ ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: _ TOTAL FEES r COMMENTS RECPT NO. PAID BY VALIDATION WH{TE—Depa6menl Copy, YELLOW --Finance Copy, PINK —Assessor Copy, GOLDENROD --File Copy, GREEN —Applicant's Copy INSPECTION RECORD Ui 0 CITY OF DIAMOND BAR c- I DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION , FIRMLY JOBSITE ADDRESS �/,�/� APN LOT TRACT _ OWNER ADDRESS CITY ZIP TEL. APPLICANT TEL. CONTRACTOR ADDRESS jqk CITY ZIP AO TEL. U ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS H- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 EUSINESSAND PROFESSIONS CODEANY CITYOR COUNTY WHICH REQUIRES APERMIT TO CONSTRUCT, ALTER, IMPROVE, DEIVI OR REPAIRANY 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 U 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 7031.5 BY ANYAPPLOANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).). O I. AS OWN ER 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. 704q 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 On TMF,000,% MIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED On OFFERED FOR SALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). El I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7D44, BUSINESS AND PROFESSIONS CODE'. THE CONTRACTORS UI CEASE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC- TORS LICENSE LAW ). ❑ 1 AM EXEMPT UNDER SEC. _ _. B. A PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM 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. LICENSE`C�ALIC. NO, DATE O "� I'� Q2, CONTRAC 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 370Q OF THE LABOR CODE. FOR THE PFRFORMANCE 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 V1.11K FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMEEH ARE CARRIER g POLICY NUMBER ITHIS SECTION NEED NOT BE CDMPLEED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS (51 DO) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN :ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, ANC AGREE THAT IF 1 S LD OME SUB�HA ORKERS'COMPENSATION PROVI SOF C'ION D H LABOR C'DHWITHCOMPLYOVISDATE:_ APPLI NT WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS LINLA L, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE DRIED THOUSAND DOLLARS (5100,OWE IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 310. OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBYAFFIRM L'NDER PENALTY 0= PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3D97, CIV. C.). LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 1 AGREE TO COMPLY WITH ALL CITY ANO 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. P M INT jA t.— SIGNA E MITTEE - ATE APPLICATION 1 �� �� PERMIT P/C DATE NUMBER # ISSUE �'` TYPE OCC DATE 1 i ( 1= CONST GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION So. FT. I FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM 12061f . J) Garage/Carport WPatio/Deck LL Pool/Spa 0 Z Re -Root 0 Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE gg •i r�C- 7G, U W J w aims-rS I Z -I �,Yk y 4/ f Q c ✓< � 1 a Z Q 2 U W CONSTRUCTION _ PLAN REVIEW _ ELECTRIC f PLUMBING _ MECHANICAL _ INSPECTION FEE ISSUANCE A �� SMIP ENERGY P/C _ ENERGY PERMIT _ RETENTION FEE: PRE-ALT FEE: TOTAL FEES _ 7 C" COMMENTS RECPT. NO / PAID BY VALIDATION WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy. GOLDENROD —File Copy, GREEN—Applican 's Copy 0 17 W 0 W 0 Z 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 PRESS FIRMLY JOBSITE ADDRESS 21s --a— / ;f / D— APN LOT / TRACT OWNER 4&V& ADDRESS / _27A 7 CITY ZIP DEL. APPLICANT TEL. CONTRACTOR ADDRESS 0 CITY ZIP —IT TEL9d Z 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 A PERMITTO 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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): 0 I, AS 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 THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR 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). ^ I, 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 OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. _ 8. & P.C. 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 LICENSE CLASS LIC. NO. DATE 46',- - 10 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 BY SECTION 3700 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 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 G 0 / . P L E T E D 0 F PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE 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 SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I 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.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY W ALL CITY COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND E EBY AUTHO IZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTKKJED P 0 RTY FOR I PECTION PURPOSES. 4zL PERMIT -FEE N PRINT) I SIGNATURE OF PERMTTTE ATE LLj Cl ti Z Q4 S 00 W W Z C'3 co 0 Ui J J Cr LLI d CD J M (/D APPLICATION PERMIT P/C DATE NUMBER F-/7 U # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW rJ / REAR /( SIDE/SIDE STREET RW SIDE PROPOSED USE NO. NO. NO. DWEL. STORIES UNITS I DESCRIPTION SFR/ADD/REM Garage/Carport W Patio/Deck LL Pool/Spa Z Re -Roof Commercial m Valuation QUANTITY z 2. 8 CONSTRUCTION PLAN REVIEW CLIMBING MECHANICAL INSPECTION FEE ISSUANCE 0 SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS BEDROOMS SQ. FT. FACTOR PSF ADJ. AREANALUATION ADJ.AREA DESCRIPTION /<<TS 7-4P AR8 & Lis V44 HER U /sS S 4 frk5 CoNn/&*a ! -V 9qo RECPT NO. L PAID BY VALIDATION 41>1 WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy CITY OF DIAMOND BAR INSPECTION RECORD 71©N L1A"—' 11, VSP --- i INSPECTION — FLQO— .--}!ST ANA R—QMTS UNDI-, FLOOR7'-' J— tJN— DATE INSPECT'C3R 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 JOBSITE ""' I—r.— �! ei Z—I i ADDRESS APN LOT — TRACT -- L —'f OWNE— %i fl ,sl3..sl.' +� ADDR SS a%t—._., iyer—i' —i —i f ,sl —>�. ; CITY —I--aTEL.' 1L°j—dc' --L 1"t) APPLICANT TEL. CONTRACTOR — 7-i)—' ... S — /," ., —,— , • —, y ADDR CITY—M—.w—I h—_ _ ZIP Lt1'1 (c—EL E- 4=i — ARCH/ENG/ ee -- 1 =ter—L ( DESIGNER ri—C:i 1 ADDRESS — --%i -iti— CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSKNS CODE: ANY CITY OR COUNTY WHICH gEWBiESA PERMITTO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, OR REPAIR ANV STRUC- TURE PRK)R TO ITS ISSUANCE, ALSO REWIRES 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 UW (CHAPTER 9 (COMMENCING WITH SECTKOJ 7000) OF DIVISK)N 3 OF THE BUSINESS AND PRO- FESSK)NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP- TKJN.ANV VKN.ATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70 A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS (5500).): ^ I, AS OWNER OF THE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSA7K7N, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW 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 ONE YEAR OF COMPLE- TKNI, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NO7 BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I, AS OWNER OF THE PROPERTY, AM EXCLUSNELV CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7041, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTMCTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG roRS ucENSE Uw.). ^ I AM EXEMPT UNDER SEC. B. d P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 0 (COMMENCING WITH SECTON 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. 1 —_ LICENSE C —ASS F " LIC. NO. — — 1 I'— J �f DATE ,) �' CONTRACTOR 1 ' ' =1 WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECURATK)NS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATKIN, AS PROVIDED BY SECTION 3700 OF THE LIBOR CODE, FOR THE PERFORMANCE //OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1! I HAVE 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. MY WOR'ER/' COMQfNSAT— I fyC—ARRIER AND POLICY NUMBER ARE: CARRIER /G- I /F \k POLICY NUMBER _ (DUS SECTON NEED NOT BE OCf.1PLETEOOF THE PERM1fT IS FOR ONE HUNDRED DOU.AHS (5700) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION UWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000E THE LIBOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNUWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLURS (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTKON 3705 OF THE LIBOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I 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.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED PROPERTY FORINSPECTK)N PURPOSES. r PERMITTE N E PRINT) '^ 1J----- SIGNATURE OF P RMIT7EE DATE WHITE -Department Copy, YELLOW -Finance Copy, PINK-Assegsoq opy, GOLDENROD -File Copy, GREEN -Applicant's Copv PRESS FIRMLY APPLICATION I — :v ^ I — DATE 1 — —. L' NUMBER #/C ISSUE f-- TYPE OCC Z Itw CONST. GROUP DATE (h ZONING SETBACKS FRONT RW ^ REAR ^ S SIDE/SIDE STREET RW ^ 1 SIDE ^ PROPOSED USE NO. DWEL. ++ NO. Z NO. r+*) UNITS f STORIES BEDROOMS — DE RIPTION SO. FT. FACTOR PSF ADJ. ARE L ATION ADD/REM Garage/Carport 1 (� , Z 1 1[! — LLI Patio/Deck ���, - U 0 W _ v PooUSpa Z Re -Roof 0 Commercial m •v..- Valuation ADJ.AREA QUANTITY DESCR TION FEE J Q U U w J W Z m a Q U Z Q 2 U W CONSTRUCTION V PLAN REVIEW ELECTRIC PLUMBING --y MECHANICAL .—G—'- INSPECTION FEE ISSUANCE SMIP of ENERGY P/C e ENERGY PERMIT RETENTION FEE: PR -T TOTAL FEES �(1 . COMMENTS RECPT. NO. PAID BV VALIDATION 1 (I ti toMTh-6 UL.'( 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 (0 PRESS FIRMLY JOBSITE ( y ADDRESS APN LOT TRACT OWNER Lig - oY) aA C1 n ADDRESS ' 1 �• /' ' Oe CITY DI"+h.cr-.. r'-v ZIP r TEL APPLICANT tn4%. Y I S r-i -.A h 4C1 1 -5- CONTRACTOR RACTOR KC- M e t—+ c- . Cm Ir c.. ADDRESS 4 9 _P ", Av CITY 6k M 0 ., (2. ZIP ("- TEL. 4 C (/ '30 ARCWENG/ 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 REQUIRESA PERMIT TO 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 Y (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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): ^ I, AS 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, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR 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). D I. 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 NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER Y (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. C 2-40 37 X LICENSE CLASS LIC. NO. DATE 04 CONTRACTOR - WORKERS' COMP ENSAT(ON•DEC T I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE D HE FOLLSWI DECLARATIONS: -I HAVE AND WILL MAINTAIN A CERTIFICATE OF N ENT TO S F-INSURE FOR WORKERS' COMPENSATION AS PROVIDED BY SECTION 3700 OF THE LA R 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 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' cOMPENSATI I RANCE CARRIER AND POLICY NUMBER ARE: 1. C/ CARRIER —.. +I cz. Y 0 POLICY NUMBER _ G n 2-6 Y S (THIS SECTION NEED NOT BE ODMPLFTED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS} I CERTIFY THAT 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 SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CAL. IFORNI D AG E THAT IF I SHOULD BECOME SUBJE T TO THE RKER ' COMPENSATI NP S ECT 37 IO 0 B 00 OF LA C WO S 0 R N S ON OR COD,I .A ITH COMPLY WITH THOSE PAO VIS S s DAT—' APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COII('ENSATION COY AGE 15 UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FIN UP TO ONE HUNDRED THOUSAND DOLLARS (f 100.000), IN ADDITION TO THE COS OF COIi7P.ENSA , DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST AND ATTORNE FEES. CONSTRUCiippi ENDI G AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE 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 INFORMATION IS CORRECT 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. -H INX-L(I ISA PERMIT -FEE NAMEftPRINT SIGNATURE P N DATE APPLICATION r7 1 5 0 L PERMIT 1' d! P/C DATE NUMBER # ISSUE 3 TYPE CC 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. AREA/VALUATION SFR/ADD/REM Garage/Carport W Patio/Deck LL PoolSpa '5 Re -Roof Commercial Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U 2 F L) W w c7 In Au d°GdiGt C— w —7SS 3 A t,— -ia,—\ CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE �) " SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT. NO PAID BY T5 VALIDATION WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy. GOLDENROD -File Copy, GREEN -Applicant's Copy 10 } IT 0 In w z 0 0 W 0 w U W 0 C-) I 0 ]C Q 0 Ii J D z Q w CO 0 M W IL } Ir w 0 IS W Q W CL C:3 C13 2 F CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS APN LOT TRACT OWNER ADDRESS CITY ZIP TEL. APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP OV TEL. U ' S 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 A PERMIT TO 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 7031.5 BYANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500)1: ^ I, AS 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 THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR 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). C I, 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 NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC. TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. 8 P.C. 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. /n— LICENSE LC --ASS a LIC. NO. L DATE L7 "— /'— Q Zs CONTRAC -- 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 3700 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 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 4 --q (THIS SECTION NEED NOT BE COMPLETED OF THE PERMITS FOR ONE HUNDRED DOLLARS ($100) OR LESS). I CERTIFY THAT 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 SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE TOME SUBJECT TOT E WORKERS' COMPENSATION PROVISION Cf.1D I SHA FORTHWITH COMPLY AFT /F DATE: APPL NT WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA L, AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE DRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I 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). LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBv AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES. &_7 F III! PX UEE 1 41- 4 7 - ATE WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy PRESS FIRMLY APPLICATION PERMIT P/C DATE NUMBER ISSUE - TYPE OCC DATE CONS. 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. AREA/VALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck LD LL Pool/Spa Z Re -Roof CI Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE W J w 0 W 4011 J' CONSTRUCTION PLAN REVIEW ELECTRIC I r L. PLUMBING MECHANICAL INSPECTION FEE ISSUANCE t •�'� SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES (-I COMMENTS RECPT NO. PAID BY VALIDATION