HomeMy WebLinkAbout15057 - 22517 LAZY MEADOW DRIVE (2)DIVIOND IIAR I
CITY
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 Z2,517 LIR�x��;.
APN_ LOT TRACT _
OWNER ►ZLZ- )C --
ADDRESS-Z'31 7 1 4z!e t�b/I�S�D/]tts i (,
CITY D_ 5,&12 ZIP 7& _ TEL. 47J_�
APPLICANT TEL.
CONTRACTOR }}f?�N="'e`}AJ[. [�i1^y ily�L Tj 4
ADDRESS J_&�;�-77 W1 Ad^% e' ` j 4 Lj- 1!?
CITY �'f-' 1 �CV61 jC ZIP ' TEL.'Z&'"2Z8_ JEl! �{
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP --_ TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS Ll
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANYCII'Y OR
COUNTY WHICH REQUIRES APERMTT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC-
TORE, 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 BUSINESSAND PRO-
FESSIONS GODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SOD).):
El 1.AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WI1 H WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70", BUSI•
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OVES OR IMPRTHEREON, 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 OFCOMPLE-
TON, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
E] I, AS OWNER OFTHE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LA.
CENSE LAW DOES NOTAPPLYTO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
❑ JAM EXEMPT UNDER SEC. S. & P.C. FOR THIS REASON
DATELICENSED
--
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENAL7Y OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECT ION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS IN FULL FORCE AND EFFECT. r
LICENSE CLASS .__"r 110. No
DATE CONTRACTOR A,R ..A7
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFANSURF 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 WIIO��RKEEA�RS GGOOM,,PE,t��•6-�.TION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRILRyt!_LTe ` off_'
r�
POLICYNUMBER-70`"'l --&t5 0A)"r
(THISSE-CTION NEEDNOT BE OOMPLE` EDOFTHE PEF5V11• 0 FORONE HUNDRED DOLLARS ($10))ORLESS).
I CERTIFYTHAT 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'COMPENSATI OVISIONS OF SE O, 37000FT LABOR
//CIlOD.E,,mI SHALL FORTHWITH COMPLYAPEI�HA.Tll.'N.11E..El.Llll.IUL.A.1)S.IILBE
S ROVISIONS.
GATE: V' �./ yam"'" APPLICAN_
WARNING: FAILURE TO SECURE WORKERS'
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (51 W.DW), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 37011 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAI' 1HPRE 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'SADDRF-SS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE. ABOVE INFORMAHON 15 CORRECT
AGREE. TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RF_LATINR TO RUII.DING
CONSTRUCTION, AND HEREBY AUTHORIZE. REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
r�S.r
r R ITTE NAME (P
Si�H EE __ __ DATE
___._._—
(fD
PRESS
FIRMLY
APPLICATION PERMIT P/C
DATE_ &-,-:E -60 NUMBER � #
ISSUE / TYPE OCC
DATE- (/) ��j ^ lY D CONST. GROUP
ZONING SETBACKS
FRONT _ RW O
REAR ❑
SIDE/SIDE STREET , RW ❑ .
SIDE n —
PROPOSED USE F . k :x-is' v
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NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. F1.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
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Garage/Carport
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Patio/Deck
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Pool/Spa
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Re -Roof
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Commercial
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Valuation __-.. ADJ.AREA......_-._
QUANTI
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DESCRIPTION
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CONSTRUCTION . _
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PLAN REVIEW -.—
ELECTRIC
PLUMBING
MECHANICAL —
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INSPECTION FEE t `•" -'
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ISSUANCE --' ,, .:" , t ?., Z/ U
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SMIP ....-... e; :41
ENERGY P/C __ _�• _... .... '.�:',_,
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:—
•
TOTAL FEES
COMMENTS
_.
RECPT. NO. -.- ..J .LL— __. PAID BY VALIDATION
WHITE —Department Copy, YELLOW --Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
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