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HomeMy WebLinkAbout15099U1;►�IIIJll BdG�� 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 APN LOT TRACT OWNER I ADDRESS CITY ZIP 9/76S�TEL. APPLICANT TEL. CONTRACTOR ADDRESS 9 CITY ZIP57_Zjj_*' TEL G/ ARC NG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENBELAW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSINESSAND PROFESSIONS CODE: ANYCITYOR COUNTY WNd1 REOUIRESAPERMITTO CONSTRLUCT.ALTER IMPROVE, DEMOLISH, OR REPAIR ANY STRUG TURF, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT ME OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER F SHE NTTl1 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 EXELP. TION.MWY VIOLATION OF SECTION 7031.6 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS (3500).): ❑LAS OIAMEROFTHE PROPERTY, ORMYEMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WOOL AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUST NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY INHO BUILDS OR IMPROVES THEREON, MEI WHO DOES SUCH WORK HIMSELFOR HERSELF OR TROUGH NO OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE MOT MENDED OR OFFERED FORS LE IF, HOWEVER 114E BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE TION, THE OWNER-SUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DD NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ LASOWNEROFTHE PROPERTY, AM EX0.USNELYCONTRACTWO WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLYTOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHOOCIRRACTS FOR SUCH PROJECTS WITMACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAG TORS LICENSE LAW.). ❑ 1 AM EXEMPT HOER SEC B. S P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION IHEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISXNS OF CHAPTER 3 (COMMENCING WITH SECTION MM) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULL FORCE AND EFFECT. LICENSE S F LIC. NO. z - DATE G'7 Q CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFdNSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _1 HAVE AND WIILMANTAN WORKERS' COMPENSATION INSURANCE AS REWIRED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSl1ED. MYN'ORKF ATION INSURANCE RIE ND POLICY NUMBER ARE: CARPoER J,y�G/a[irj , b POLICY NUMBER MISSECTIONNEEDNOTBEaAWLEfEJOFTI-E PEFMTIS FORCNEHU DREDDOIIARS WOO) OR LES% I CERTIFY THAT N THE PERFORMANCE OF THE W13M FOR WHICH THIS PERMIT 15 ISSUED, I SMALL 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 WORKERT COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR COOS, I SLULLL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECTAN EMPLOYER TO CRIMWAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (3100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. - CONSTRUCTION LENDING AGENCY 11EREBYAFFIRM LAMER PENALTY OF PERJURY THAT THERE R A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. C.). LENDERS NAME LENDER'S ADDRESS i CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WRH —CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BINDING CONSTRUCTION,LM AHEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERM NAMEIP sioITAT0R&eFfeFQrrrE9 DATE PRESS FIRMLY APPLICATION I PERMIT f ©� P/C DATE NUMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE JS NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA(VALUATION SFR/ADD/REM Ui Garage/Carport WPatmi'Deck LL Pool/Spa Z Re -Roof Commercial - m Valuation ADJ.AREA OUANnrY DESCRIPTION FEE J Q U cc U W Lu W C.7 Z CL J Q U Z Q 2 U W g CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE , ' `5 I— Al". _ ISSUANCE- SMIP _ ENERGY P/C ENERGY PERMIT PAR RETENTION FEE: ` Fes:: I: `' PRE -ALT FEE: TOTAL FEES COMMENTS —I I h!1 1) /I L d RECPL NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy. GOLDENROD --File Copy, GREEN—Applicant's Copy