HomeMy WebLinkAbout14566 - 2702 SOUTH GEORGE LANECITY 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/�
ADDRESS-' l r) ef. "�� '(Ils k4j
M APN LOT � TRACT _
OWNER �
CITY N PI-eI t Hai ZIP t 1 fit' TEL��/'° Sa> ud L)
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCHIENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF
CENSE UW (CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION 3OF THE BUSINESS AND PROP
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 703'.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS 13500) )'
❑ 1•ASOWNEROF THE PROPERTY. OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IB 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 THESUILDING ORIMPROVEMENT IS SOLD WR HIN ONEYEAROF OOMPLE.
TO CONSTRUCT THE PROJECT (SEC 7044•06SINESS AND PROFESSIONS CODE THE CONTRACTORS LI.
CENSE LAW DOES NOT APPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC.
TORS LICENSE LAW.)
❑ 1 AM EXEMPT UNDER SEC — B S P C FOR THIS REASON
DATE tr �__—' OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT] AM LICENSED UNDER PROVISONS 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
DIATE CENSECr8S,, PIZ) _ LIO NO. _
7 ano CONTRACTOR —
WORKERS'COMPENSATION DECLARATION `/•��/f/-/�'
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOW,NG DECLARATION¢
I HAVE AND WILL MAINTAIN A CERT ITICATE OF CONSENT TO SELF.NSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION SrW OF TI IE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
---I HAVEAND WILL MAINTAIN WORKER5' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
SI00 OF THE LABOR CODE. FOR FHE PERFORMANCE OF THE WORK FOR W^ICH THIS PERMIT IS
ISSUED M ER§j rMPENSATKKJINSUR 'gRRI HAND POLICY NUMBERARE
CARRIER _�_�g•y- (/�. 1Y.1,�``/-'�
-�-1POLICY NUMBER ✓�H�_ -
(1}iL4SECRONNI-ED NOT BE COAPLETEDOFTHE PERM IS FOR EHUMN)REf DOl1AfS($ i LE
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PER UED, I
. .' '.ti N •• �r'•: �r� TO THE
1)BECOMF
• =THE LABOR
COD , I SHALL FOflTHWITH COMPLY WITH THOSE PROVISIONS
DATE. _IPPLICANY
SECTION 370BOF THE LABOR CODE, INTEREST, ANDArTORNEV'S FEESV
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT T14FRF IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH T HIS PERMIT IS ISSUED (SEC 3097, CIV C )
I
LENDER'SADDRESS _----- ---- ----
i I CERTIFY THATI HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
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� PEFlMITTE ME (P
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SIGNATURE. OF PER E DATE
PRESS
FIRMLY
DATEAPPLICATION��,` i �' r; PERMIT
�� NUMBERI p/ / `',
ISSUE TYPE OCC
DATE CONST• GROUP
ZONING SETBACKS
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SIDEISIDE STREET RW f_1
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PROPOSED USE
NO_ DWEL. NO. NO.
UNITS STORIES BEDROOMS _
DESCRIPTION
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FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
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ENERGY PERMIT
RETENTION FEE_-
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COMMENTS
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RECPT NO PAID BY
WHITE —Department Copy, YELLOW--Finanoe Copy, PINK —Assessor copy, ULnL1JeNKLnJ—NIe L;DPy, LtHeeN—Appucaru s i upy
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