HomeMy WebLinkAbout8716CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
216601- Copley Drive Suite 190
909) 860.3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION /
00ESS d G G12t 7 P
APN- LOT TRACT
OWNER R4 N `
ADDRE S
CITY TE
APPLICANT TEL
CONTRACTOR
ADDRESS L FtJ
CITY Rix., 111 ZIP '/;t4-7 TEL U'
ARCRENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFRRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LY
CENSE LAW FOR THE FOLLOWING REASON (SEG 7071.6 BUSINESS AND PROFESSIONS CODE ANY CRY OR
COUNTY WHICH REGURESAPERMITTO CONSTRUCT ALTER IMPROVE, DEMOLISH. OR REPAIRANY STFM
TORE, PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
CENSE UW (CHAPTER I (COMMENCING WITH SECTION YOM) OF DIVISION 5 OF THE BUSINESS AND PRO-
FESSIONS MOE) OR THATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THEALLEGFD EXFMP.
TON. ANY VIOLATION OF SECTION 7671.5 By ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSM),y
D L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES VAIN WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUS4
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY VMO BUILDS OR IMPROVES THEREM AND VMO DOES SUCH WORN HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE M DNG OR IMPROVEMENT IS SOLD WITHRONE YEAR OF COUPLE.
TION, THE OWNER-0BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT COSEC, 7044, BUSINESS AND PROFESSIONS DE: THE CONTRACTORS U,
CENSE LAW DOES NOT APPLY TO AN OWNER O' A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR CHSUPROJECTS WIT14AOOMMCTOR(S) UCENSED PURSUANT TO THE CONTRAP
TORS LICENSE LAW). _
U 1 AM EXEMPT UNDER SEC. B. a P.C. FORTHIS REASON
DATE OWNER
UCENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UN DER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (COMMENCING WITH SECTION TOM) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE AND
UY LICENSE N N FULL FORCE AND EFFECT.
LICENSE CU Si ' / LLC. NO.
7.
DATE I-
1jY
CONTRACTOR
rWORKERT 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'
COAPENSATON, AS PROYOM BY SECTION 3700 OF THE LABOR MOE, FOR THE PERFORMANCE
OF THE WORK FOR WHIG( THIS PERMIT IS ISSUED.
1.—AND WILL MAINTAIN W ORKERS'COAPENSATION NSURANCE. AS REQUIRED RY SECTION
5700 OF THE LABOR COOS FOR THE PERFORMANCE OF THE WORK PoR WHICH THIS PERMIT IS
ISSUED. MY WOORKERT ODMPE_NSATION ARRIER AND POLICY HAMER ARE:
CARRIER 601-0
POLICY NUMBER
SECTION NE® NOT BE R7.(SETID OF THE POW LS PORCINE HU DRFD DdUR4 MIM OR LESM
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR R ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERT COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 5700 OF THE LABOR
COO L FORTFANTH COMPLY W7N1 TF1D Ef y$SID /
DATES I ( APPLICANT: N -
WAfINIHXFALUR TO SECURE WDRKERT COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CNL FINES UP TOONE HUNDRED THOUSAND
DOLLARS (itm,6661. N ADDnON TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 5)OF OF THE LABOR OBOE INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AF SAM UNDER PENALTY OF PERJURY TR&T THERE IS ACONSTHUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORI( FOR WHOCF THIS PERMIT IS ISSUED (SEC. 5097, CIV C.),
LENDERS NAME
LENDER'S ADDRESS - - -
1 CERTIFY THAT 1 HAVE READ TMS 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 REPRESENTATIVE OF THS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERLaTTEE E(PNHT) :
3 / - C!L
SIGNATUREOIPPERMIrTEE DAT
PRESS
FIRMLY
APPLICATIO`--'
i
PERMIT l'. PIC .
DATE NUMBER 1
ISSUE TYPE OCC
DATE- CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR
SIDEISIDE STREET RW
SIDE
PROPOSED USE
NO. DWEL NO.NO.
UNITS STORIES- . BEDROOMS
DESCRIPTION 50. FT. FACTOR PSF ADJ. AREWALUATION
SFRIADD/REM
co Garage/Carport
W PatID/Dfw*
LI- PoOVSpa
ZRe Roof vs If
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
CrU
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DO
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PLAN REVIEW jyUNN N nowinHt) `
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PLUMBING i
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PIC
T
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE
TOTAL FEES 2323
COr'
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RECPT. NO. ^ PAID BY VAUDATION
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