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HomeMy WebLinkAbout15142CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 BUILDING PERMTI' APPLICATION r, JOBSITE Ic1 ADDRESS APN LOT TRACT OWNER ADD lair CITY Z TEL. APPLICANT TEL. CONTRACTO ADDRE CITY ZIP TJ TEL ARCHIENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4 CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.3 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNIYW WH REOLARESAPERMrTTOCONSTRUCT,ALTER IMPROVE, DEMOLISH, ORREPAIRANYSTRUCF TURF, 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 UW ICHAPTER 0 (COMMENCING WITH SECTION 71100) OF DIVISION 7 OF THE BUSINESS AND PRO- FSSSIOkS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXFMP- TION. ANY VIOLATION OF SECTION 7MI.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACRAL PENALTY OF NOT MUTE THAN FIVE HUNDRED DOLLARS (55001.): O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WHA CO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, SUSI- NE&S 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 FORSALEIF, HOWEVELTHE BUILDING ORIMPROVEMENT IS SOLD WITHINONE YEAR OFCOMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DW NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑LAS O"GA OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70M. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U. CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRACTS FOR SUCH PROJECTS WITHAOONTRACTOR(5) LICENSED PURSUANT TO THE DONTRAG TORS LICENSE LAWJ. O IAM EXEMPT UNDER SEC. B. M P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 0 JOOMMENCIIG WITH SECTION 7")OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE LS W FULL FORCE AND EFFECT. LICENSEUC. NO. .A. ZlZUDI CONTRACTOR_vv—. WORKERS' COMPENSATION DECLARATION O I HEREBY AFFIRM UNDER PENALTY OF PENURY ONE OF THE FOLLOWING DE ZT I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INS .ERS` OOMPFNSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE - OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. r,- _1 "AVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOUI BY SECTION 3700 OF THE LABOR CODE "FOR THE PERFORMANCE OF THE WORK FOR WH THIS PERMIT IS ISSUED. MY E czIc.PENSATTr INSUR CARRIER MND POLICY UMB RE: CARRIER POLICY NUMBER (THIS SECRONNEEDNOTIEOMPLE(EDOFTOEPERWISFOR ONE HUNDRED oauA . OR I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED, I SHALL NOT EMPLOY ANY PERSON W 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 37M OF THE LABOR i CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS I DATE: APPLICANT: I j WARNING: FAILURE TO SECURE WORKERSCONPENSATK744 COVERAGE ISUNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I SECTION 37044 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. ( CONSTRUCTION LENDING AGENCY i 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3017, CIV C.). 1 LENDER'S NAME LENDERSADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABDVE-MENT ED P ERice, R INSPECTION PURPOSES. "AQ �l� i D PERM) i �esie� rol�,�ao D SIGNATURE OF PERMITTEE DAT i li PRESS FIRMLY APPLICATION a PERMIT//la P/C DATE NUMBER 7 M ISSUE TYPE OCC DATE v V CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE O IA 1 r Z3 MLcu I DWELL NO. NO. UNITS % STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM C/) Garage/Carport W PaWIDeck LL POOVSpa ZRe -Roof Commercial - m Valuation ADJ-AREA QUAN11TY DESCRIPTION FEE J Q U s F- U w J Lu 0 Z J CIL Z 6 w f IQ OSTRU ION PLAW TRIC PLUMBING MECHANICAL _ M"'`I n INSPECTION FEE - ISSUANCE SMTP ENERGY PIC ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES 5(� COMMENTS RECPT. NO, PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance COW PINK—ASSBSSO' L;Opy, t L)LUt YHU1r 118 L,Opy, UMCC PII PIIGHFII3 UUPY ITY OF D$ A MiO ND Bm. 111 c. v, .r.