The URL can be used to link to this page

Home My WebLink About15049CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION ADDRITE SS APN LOT TRACT OWNER ADDR-.f 4— L CITY i¢!2 _ ZIP TEL APPLICANT,. «AACg �s TEL/," -!ifs!; CONTRACTO a ^14. ADDRES CITY ZIP TE ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION I HER®Y AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSNESSAND PROFESSIONS OW E: ANYCTYOR CORNTVWI I" REOUAESAPERMITTO CONSTRUCT,ALTER IMPROVE, DEMOLISH, ORREPAIRANY STRUC- TURE, PRIOR 70 ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIQNW STATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE SUSINESSAND PRO- FFSSONS CODE) OR THATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SWnON?=.S BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (11SIXI ): D LASOWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC, 70U, BUSI- NESS AND PROFESSIONS COD@ THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF PROPERTY WHO BUILDS OR MPROVESTHEREC{ AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THRO(M HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE BIMDNGOR IMPWWMENTISSOLD WITHNONEYEAROFCOMPLE- TION, THE OWNERN3tADER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 00 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} ❑ L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LCENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. ?041, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CEFRE UW DOES NOT APPLY TO AN OWNER OFA PROPERTY VMO BUILDS OR IMPROVES THEREON, ANO WHO CONTRACTS FOR SUCH PROJEM MTNAOONTRACTOR(5) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). O 1 AM EXEMPT UNDER SEC. B. M P.C, FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I RAY AFFIRM UNOER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER f (COM MEN CING WITH SECTION TOM) OF DMSION 3 OF THE BUSINESS AND PROFESSIONS (SIDE, AND MY LICENSE 6 N FULL FORCE AND EFFECT. LICENSE CLASS T LIC. NO. !C/G/ ✓/ DATE(&7 ^Q1 CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PENURY ONE OF THE FOLLOWING DECLA S. I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEURNSURE WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE F R THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. - _I NAIVE AM WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIR SECTION 31M OF THE LABOR WOE, FOR THE PERFORMANCE OF THE WORK FOq THIS PERMR I LSSllEO. MHY WDfI(FAS'OOMPENSATKNN cuiRIERAD POL NUMBER ARE: CARRI d POLICY NUMBER (MSSSMDNA®NOT HECOPLETEDOFTHE PERMIT IS F08 ONE MUMS 100)OR� 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WNICI THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WOROEFw COMPENSATION LAWS OF CALIFORNIA AND AGREE TUT IF 1 SHOULD BECOME SUBJECT TO THE WOR(ERV COMPENSATION PROW SONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PFOVISKN APPLICANT WARNING: FAILURE TO SECURE WORKERS' COMPENSATION RAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR OWE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY N 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. 3037, CIV C.). LENDERS NAME LENDERSADORESS I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT. 1 AGREE TO COMPLY WDH ALL CITY AND COUNTY ORDNANCE$ ANO STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. K-�I I A %fit d PEPAI�TEE n/l/Jd MGMATURE OF PEMITT DATE DFPRESS FIRMLY APPLICATION PERMIT ' P/C ( DATE NUMBER 1 U # ISSUE. TYPE OCC DATE CONST, GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE TJeaL.— O >�� iSif�D�6et4^ 71-, K - ,MflCSp NO. D NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO, FT- FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM Garage/Carport W Patio/Dock LL PooVSpa ZRe Roof " Commercial -- m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U U LU LU CD O] Z 4 U W ��• CONS CTION /V PLAN R AEW ELE IC LUMBING MECHANICAL 77r,%7 INSPECTION FEE ISSUANCE SMIP ENERGY P/C t IiTV (X: ENERGY PERMIT,'' RETENTION FEE: PRE -ALT FEE: TOTAL FEES �U COMMENTS RECPT. NO. PAID BY VALIDATION _ WHITE—Deponent Copy, YELLOW --Finance Copy, PINK—Assessor COW GOLDENROD --File CGpy, GREEN—Appllcaht's Copy �4