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Home My WebLink About17885CITY OF DIAMOND BAR - - DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY / �( jrODDR TE ADDRESS ESS d6 ✓ 1 �(.�t iJ 1- /C� i Lzi, 4, f/ APN LOT /TRACT — 7 -- OWNER ADDRE S CITY _ ZIP / 7EL- APPLICANT TEL. CONTRACTOR ADDRESS CITYZIP TE �:> ARCH/ENG/ I Z DESIGNER ADDRESS CITY ZIP _ TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� CENSELAWFORTHEFOLLOWING REASON(SEC. 70 tS BUSINESS AND PROFESSIONS CODE: ANY CITYOR 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 UCENSEO 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- 'RUN. ANY VIOLATION OF SECTION 7031.5 BY ANY APP_ICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500I.): ❑ I, AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, 9USI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVE$THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPRCVEMENTSARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- TION, THE OWNER•BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODES THE CONTRACTORS U, CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & PC. FOR THIS REASON DATE _ OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION a OF THE BUSINESS AND PROFESSIONS CODE, AND My LICENSE IS IN FULL FORCE ANDDyEFFECT. LICENSE CLASS I� I � &, e LIC. NO, �'� J� z_/ DATE � p' CONTRACTOR? L �i .J `�,�' /y i WORKERS' COMPENSATION DECLARATION 1 I 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS. 1 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 1 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 1 ISSUED. MY WORKERS' ENSATION INSURANCE CARRIER ANDDPCLICY NUMBER ARE: CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED 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 j SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 370U OF THE LABOR D CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. � DATE: __ APPLICANT: J J WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROV IUED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY C 1 HEREBY AFFIRM UNDER PC NALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY L FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3097, CIV. C.). I C LENDER'S NAME LENDER'S ADDHESS - - C I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. LI I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING L. CONSTRUC ION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-M TKNJED PROPERTY FOR n IN CTK)N P POSES. PE MITTEE (PRINT f3 n rj SIGN A (7 iRFP DATE = l WHITE —Department Copy, YELLOW Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Gopy APPLICATION PERMIT �'G Pr P/C DATE NUMBER M ISSUE ( ' 01 TYPE OCC 1 Vy CONST. GROUP DATE ZONING SETBACKS FRONT RW C REAR G SIDE/SIDE STREET RW ❑ SIDE O PROPOSED USE NO, DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION So. FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM Garage/Carport (1) WPatio/Deck LL PooVSpa o Z Re -Root Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U U W J Uj (D z Jm a J Q U_ Z Q 2 U CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY PIC ENERGY PERMIT - — RETENTION FEE: PRE-ALT FEE: _ TOTAL FEES " (5 u COMMENTS -17 RECPT. NO. PAID BY VALIDATION — loom HZ — � i no wEA ",,y m kid ITS ` MIT I win 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 f/- y APN LOT TRACT OWNER ADDRESS CITY 12 , • ZIP 4 ( TEL. APPLICANT TEL. CONTRACTOR 'IliL ADDRESS CITY 41'—t—t3,—u—,—I ZIP TE ARCH/ENG/ t— #V51 DESIGNER 7 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 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500)): U I, AS OWNEROFTHE 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, 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 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.). 0 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. LICENS fr Z E CLASS LIC. NO. v I DATE CONTRACTOR/—! f 4. 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' ENSATIO N INSURANCE CARRIER /AN POLICY NUMBER ARE: ON CARRIER / M/r(r I POLICY NUMBER - 2 C,? / , -z (IRIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS (E100) 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 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 15 UNLAWFUL, AND SHALL BE SUBJECT AN 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 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-M TION ED PROPERTY FOR IN CTION P POSES. PE MITTEE (PRINT SIGNA fl F P DATE WHITE -Department Copy, YELLOW -Finance Copy, PIN APPLICATION qLj 11 i Sam/ 0"— PERMIT -- P— p/C DATE NUMBER ISSUE [0 TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR SIDE/SIDE STREET RW SIDE I] PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport LU Patio/Deck LL PooI/Spa Re -Roof Commercial Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U W W I U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE- T OTAL FEES 15 COMMENTS 114, RECPT. NO. PAID BY VALIDATION PRESS FIRMLY