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Home My WebLink About18992F C C u u O 0 C O U CITY OF DIAMOND BAR p� f DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive PRESS (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION FIRMLY ADDRIESS ,kL Z0 ' -'S N�N r0.10LI'VIF K lr APO-- LOTTRACT OWNER VLA ki �� rLL I, /'T� D ,r ADD�5 $S 17 .2, f� S 9??� 12 n V r �Jl� CITY V i "JOAAG .RQ ZI P Tj ZLk 5 TE LVE APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP TEL. ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOURESAPERMIT TO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, OR HEPAR ANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER P (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- TON. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 01, AS OWNEROF THE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE. THE CONTRACTORS LICENSE LAW 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 ONEYEAROF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FORTHE PURPOSE OF SALE). 0 1, AS O WNEROF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 70", BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(5) LICENSED PURSUANTTO THE CONTRA, TORS LICENSE LAW.). 0 I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER o (DOMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS ANU 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: _ I 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 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 WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER i (MISSECTION NEEDNOTSECM(PL=OFTHE PERM LSFDRONEHUNDREDDOLW7S(SM)ORLESSI I I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT fS ISSUED, I f SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. 1 1 DATE: APPLICANT: i WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE _ SUBJECT AN EMPLOYER TOCRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($10O,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN J SECTIDN3708OFTHELABORCODE. INTEREST. AND ATTORNEY'S FEES. J 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. 3087, CN. CJ. _ IENOER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS AP PLICATION 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-MENTIONED PROPERTY FOR INSPECTION PURPOSES. = P TTEE NAME (PRIdT) O O IG RE OF PERMITTEE DATE _/ _, C (J APPLICATION1 �. „ f 1 PERMIT P/C DATE I v d�NUMBER S ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW-0- W❑SIDE SIDE p PROPOSED USE I, �} �'i fi C- �• NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM CO GaragelCarport Patio/Dock LIJ LL PooVSpa 0 Z Re -Root 0 Commercial In Valuation i ADJ.AREA QUANTITY DESCRIPTION FEE J Q U cc f— U W J w 0 Z m J CL J Q U Z Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE J V ISSUANCE SMIP ENERGY P/C —_ ENERGY PERMIT RETENTION FEE: (• V U PRE -ALT FEE: TOTAL FEES 1 COMMENTS RECPT NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor GOpy, UULUI= NHIUL! 110 UOPy, umnit—hppocam s a py "'ND BAVI IAI . z A° x. 3" H]T IAI CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE ( O ADDRESS/120 1 S- c 4"y J /I,fit APN LOT TRACT OWNER ADD $S 1r33,C1 CITY i It IOXk 0" ZIP'/L2 TEL' D a4/ —f—,7 APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP TEL. ARCWENG/ 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 CODE: ANY CITY OR COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT, ALTER. IMPROVE, DEMOLISH, OR REPAIR ANY 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 FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): 0 1. AS OWNER 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. 7044, BUSI. NESS AND PROFESSIONS CODE. THE CONTRACTORS LICENSE LAW 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, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 0 1, 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 DOES NOT APPLY 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.). 0 I AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I 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 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 WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (THB SECTION NEED NOT BE Cd,1PLETEDOFTHE PERMIT IS FOR ONE HU DREDDOD.ARS ($100) 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 LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST. AND ATTORNEY'S 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 NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I 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-MENTIONED PROPERTY FOR INSPECTION PURPOSES. P TTEE NAME (PRILJT) IG RE OF PERMITTEE DATE,,/ APPLICATION - . j PERMIT ( "P/C DATE UMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ ,—}} PROPOSED USE t k —4 d c. 4L- 13 NO. DWEL. otr R, NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck LL PooVSpa 0 Re -Roof Z Commercial m Valuation I G621 0 ADJ.AREA QUANTITY DESCRIPTION FEE w W CL U UJ CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE JV SMIP J ENERGY P/C ENERGY PERMIT RETENTION FEE: I , V PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy /yolC /7-1 ,twf/viri 0 na w< .—av rim r,— =)rq,