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HomeMy WebLinkAboutPR 11-16150 m CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPINIENT SERVICES 21825 Copley Drive, Diamond Bar, CA 91765 (909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7Q�7^ BUILDING PERMIT APPLICATION V R/ V RE SS" FIRMLY APPLICATION DATE PERMIT I�p/C NUMBER ADDRIESS C�925IAII ISSUE ) DATE lI 2 CONTYPE CONS APN LOT TRACT OWNER ArO V V1 Q Y 1 ADDRESS CITY ZIP TEL. APPLICANT TEL. �4 CONTRACT05h A tl ADDRE$ CIN C ZIP ( J -TEL. ARCFUENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSEE LAW FOR THE FOLLOWING REASON (SEC. 7071.5 BUSIN ESS AND PROFESSIONS COO -E: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, OR REPAIR ANY STRUC. TURE, PRIOR TO ITS ISSUANCE. ALSO RECUIRES 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 CIVILPENALTY OF NOT PADRE THAN FIVE HUNDRED DOLLARS ($500),): E31, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH.WAGES AS THEIR SOLE COMPENSATION, WILL DO THE YORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI. NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAZY 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, /fIWNER-BUILDER WILL HAVE THE BURDEN OF PACING THAT HE OR SHE DID NOT BUILD OR V IMPROVjIFOF, THE PURPOSE OF SALE). 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 DO -ES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW). - ❑ I AM EXEMPT UNDER SEC. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 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. LICENSE CLASS LIC. NO. DATE CONTRACTOR 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 SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WCRK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WJORI(ERS' 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' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (IHS SEC T CH NEED NJT BE COPAPLEfED OF THE PEMAT IS FOR Cc=_ Rkrr.'�� DOLLARS (5100) 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 LA'NS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37M OF THE LABOR CODE,1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT: WARNING: FAILURE TO SECURE VIORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND 00 DOLLARS (3100.0), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. INTEREST AND ATTORNEYS 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 NAM' LENDER'S ADDRESS l 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 BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE�NED PROPERTY FOR Irr\\SPECT gN,P/U^RP'OSES. r 1 PERMITTEE NAME(PRI i 1 L I I,–,,– — 1 1 – SIGNATURE OF PERMITT DATE V RE SS" FIRMLY APPLICATION DATE PERMIT I�p/C NUMBER ISSUE ) DATE lI 2 CONTYPE CONS ZONING SETBACKS FRONT RW REAR 0 SIDE/SIDE STREET RW p SIDE 0 - PROPOSED USE G ei lS � .VIX If NO. DWEL. i uF A N0. UNITS TORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM U) Garage/Carport wLI Patio/Deck L LL 0 Poo!/Spa Z Re -Root 0 Commercial 13 m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U cc F— U W LU W CD Z m J d Q _U Z Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE W. /0 SMTP G v ENERGY P/C ENERGY PERMIT RETENTION FEE: . p©, y0� TOTAL FEES ! 517 COMMENTS RECPT. NO_ PAID BY r VALIDATION wnD E—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—Fila Copy, GREEN—Applicant's Copy f3oLl j vv-%- ak