HomeMy WebLinkAbout14898 (17)CITY 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 _ 1 t;. R Inc
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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 CODE: ANY qTY OR
CQIANTY WFaCli ITS SAPERMRTO CONSTRUCT ALTER,IMPROVE, DEMOLISH, OR REPMR ANY STRUC
TURF. PRYPH TO RS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATL�IEM THAT HE OR SHE IS LICENSED PURSUANT TO THE PROV1510NS OF THE CCWTRACTORS 1 I.
CENSE LAW (CHAPTER I (COMMENCING WITH SECTION 7040) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CMF) OR THAT HE OR SHE 19 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORA PERMIT SUFUECTS THE APPLICANT TO
A CML PENALTY OF N0
7 MORE THAN FIVE HUNDRED DOLLARS (I^ ).).
❑LAS OWNER OF THE PROPEPTY.OR MY EMPLOYEES WTH WAGES AS THEIR SOLE COMPENSATION,
N1AL DO THE WOR!(, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. X4A. BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY M40 BUA.DS OR IMPROVES THEREON, AND WHO DOES SUCH WOW HUSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARF NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE MAUDWGOR IAPROVFIAENT IS Sol -0 WITHIN ONEYEAROFCOMPLE-
TION, T11E OW NER"BUtl DFA WILL HAVE THE BURDEN CF PROVING THAT HE OR SHE DD NOT BUILD OR
APPROVE FOR THE PURPOSE OF SALE).
❑ L AB OVIWROF H1F PROPERTY, AM EXCLUSNELY CONTRACTING WTTH LICENSED CONTRACTORS
TOCONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PRCFESS'ONS CODE: THE CONTRACTORS LI-
CE
NSE LAW ODES NOT APPLYTO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FM SUCH PROTECTS WnHA OONTRACTOP?S) LICENSED PURSUIT TO THE CONTRA, -
TORS UCENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. S. A PC FOR THIS REASON
TE ' o OWNER '
LICENSED CONTR , FORS DECLARATION
I HERESY AFFIRM UWE9 PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHA?TE9
I (COMMENCING 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.
DAZE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
HEREBY AFFIRM UNDER PENALTY OF PENURY ONE OF 7U FOLLOWING DECLARATIONS:
_I HAVE AND WLL MAINTAN A CEPnF[CATE OF CONSENT TO SELFJNS'IPF FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 37W OFTHE LABOR CDD E. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED_
I HAVE AND WILL MAINTAIN MW7RERS' 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' CDWENSATIDN INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICYNAIMBER
(THIS SEC ION NE®NOT BE THE PERMITS FOR OW HUIIDRFDD011AAS($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' C OMPEN.SATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TD THE WORMERS' COMPENSATION PROVISIONS OF SECTION3700 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 COIL FINES UP 10 ONE HUNDRED THOUSAND
DOLLARS H100,OM), 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. 3087, CIV. C.).
LENDERS NAME
LENDERS 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 RFPRESENTATIVES 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 i
DATE ` NUMBER! #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
ROPOSED USE 10(.1T ah i? e -w 9
eaii v ¢ .
57
NO. DWEL. NO, NO.
UNITS I STORIES BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
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OU DESCRIPTION FEE
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CONSTRUCTION .
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL _
INSPECTION FEE
ISSUANCE
SMTP _ — 0
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