HomeMy WebLinkAbout14700CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax (909) 861-3117
"•A BUILDING PERMIT APPLICATION
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APN LOT TRACT
OWNER T c
ADDRES
CITY h ZIP . y TEL. ITO
APPLICANT TEL.
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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 CODES ANY CITY OR
COUNTY WHICH REQUIRESA PERMITTO 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 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 FORA PERMIT SUBJECTS THE APPLICANT TO
' Ai(:Vi1••'i1 , Y •A A" V
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
THEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR
'•M;•::'••:•�.IF•T •°:11;✓:\ u' •'rS, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
Irx+:•• ::r�1.' �•i:A'.+: •-•iULDNGORIMPROVEMENTISSOLDWrTHINONEYEAROFCOMPLE-
- I % ' '�A\THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
LI I, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70". BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
U I AM EXEMPT UNDER SEC B & P.C. FOR THIS REASON
DATE ._ OWNER_—_
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHA R�
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3OF THE BUSINESS AND PROFESSIONS ,AND
MY LICENSE IS IN FULL FDRA AND EFFECT _
LICENSE CLAS LIC NO - �.�
DATE _- 1'l CJ — CONTRACTOR._-_
rf J 1/
WORKERS' COMPENSATION DECLAATIONI
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATICNS
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
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CARRIER � `7 T`��' '..�L �'(' ? ,, �'','" •
POLICYNUMBER J/• Z1\••- T�•- ))j JI
(THIS 8ECTICtJNFED TBE D T�PlAIT ONEk' oOIIARS (8fm
A.
h 'A,
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE' _ APPLICANT
WARNING- FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE NAWFUL, AND SHALL BE
CONSTRUCTION LENDING AGENCY
t HEREBY AFFIRM UNDER PENALTY OT 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'SADDRESS
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 13UIL DING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABO MENTIONEDPROPE Tfi YFOR INSPECTION PURPOSES
PERMITT NAME( T)
KIGNNALTREOF LIITTEE (1AIt
PRESS
FIRMLY
APPLICATION3 �U PERMIT P/G 6� I ,
DATE NUMBER 0 iJ
ISSUE ) TYPE OCC
DATE r CONST. GROUP
ZONING SETBACKS
FRONT RW fl _
REAR Li
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREANALUATION
SFRIADD/REM
Garage/Carport
WPatio/Dock
u-
Pcol/Spa
0
Z
Re -Root
Commercial
03
Valuation
ADJ.AREA
QUANTITY
DESCRIPTION
FEE
Q
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F-
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W
J
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0
Z
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1
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CONSTRUCTION
P N REVIEW
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MBING
2'CHANICAL
INSPECTION FEE
ISSUANCE
SMIP-
ENERGYPIC �//���� ��{{(y
ENERGY PERMIT 1tj-�
RETENTION FEE:---
PRE-ALT FEE: JI
TOTAL FEES IE7- 3
COMMENTS
RECPT. NO.. _ VALIDATION
WHITE —Department Copy, YELLOW—Financs Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy