HomeMy WebLinkAbout14898CITY OF DIAMOND BAR
-�--- DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES f —
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
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APN LOT TRACT
OWNER _ �6, iWLr. Pint 17 Y'
ADDRESS gr -,Se PYl d hrP 7
CITY ZIP "11Z L��-'TEL. ff6 J - 7 3 7
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCHIENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I NORM AFFIRM UNDER PENALTY OF PERJURY THAT 1 Am EXEMPT FROM THE CONTRACTORS 1.1 -
LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSNESSAND PROFESSIONS COOT: ANY CITY OR
CQIANTY WENCH
TO ITS
TITS SAPERMRTO CONSTRUCT ALTER, DEMOLISH, OR REPMR ANY STRUC
TURF PRYPH ISSl1ANCE, ALSO REQUIRES THE APPLICQ4T FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFIOVLSIONS OF THE CONTRACTORS LI
CENSE LAW (CHAPTER Y (COMMENCING WITH SECTION 7—) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CME) OR THAT HE OR SHE 19 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 703.6
BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF N0
7 MORE THAN FIVE HUNDRED DOLLARS (t^ ).).
❑LAS OWNER OF THE PROPEPTY, OR MY EMPLOYEES WTH WAGES AS THEIR SOLE COMPENSATION,
N1AL DO THE WOR!(, AND THE STF!UCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7WA, BUSI-
NESS AAO PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PE
PRORTY M40 BUILDS OR NPROVES THEREON, AAD WAIO DOES SUCH WORK HU SELF OR HERSELF OR
THROWN ILLS OR HER OWN
EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARF NOT INTENDED OR
OFFERED FOR BILE IF, HDWEV'RL THE OULDNGOR IMPROVEMENT LS SOLD WITHIN ONEYEAROFCOMPILE
-
TION, THE OW/IEA41Utl GFA WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DW NO. BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
LI L AB OWNEROF HUE PROPERTY, AIA EXCLUSIVELY CONTRACTING WITH LICEM4ED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PRCFESS'CNS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLYTO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FDA SUCH PROJECTS WITHA OONTRACTOPIS) LICENSED PURSUANT TO THE GYWTRAG
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. S. A PC FOR THIS REASON
TE ' vz,010,6OWNER
LICENSED CONTR , FORS DECLARATION
I HERESY AFFIRM UWE9 PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHA?TE9
P (CONYENCFKN WITH SECTION 70w) OF DMSION 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
HEREBY AFFIRM UNDER PENALTY OF PENURY ONE OF 7U FOLLOWING 0 ECLARATION S:
_I HAVE AND WILL MAINTAIN A CEPRFCATE OF CONSENT TO SELF4NSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 37W OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED_
I HAVE AND WILL MAINTAIN LW7pIENS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
37W OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' CDWENSATDN INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NE®NOT BE COMPLETED OF THE PERMITS FOR OW /IIlDRFDDOLLARS ($100)OR LESS?
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION OMPEN.SATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT
SECTIONTD THE WORKERV COMPENSATION PROVISIONS OF SECT3700 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 10 ONE HUNDRED THOUSAND
DOLLARS (1100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK EGA WHICH THIS PERMIT IS ISSUED (SEC. 3067, CIV. C.).
LENDERS NAME
LENDERSADDRESS
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 HERESY AUTHOiIQE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
P NAME (PRINT)
E OF PERMITTEE DATE
PRESS
FIRMI V
APPLICATION PERMIT + P/C
!
DATE ` NUMBER!
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE p
ROPOSEDUSE 10.4T 0 k i? e -Cts 9
1' a Il 01EF-
NO. DWEL. NO, NO.
UNITS I STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
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Garnowcarport
WPatiolDeck
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Pool/Spa
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Commercial
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OU DESCRIPTION FEE
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CONSTRUCTION .
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL _
INSPECTION FEE
ISSUANCE
SMTP _
ENERGY P/C
ENERGY PERMIT '
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES /
COMMENTS
RECPT. NO. PAID BV ALIDATION
WHITE—D"rhIlAnt COPY, YELLOW—Finance Copy, PINK
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