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Home My WebLink About15061CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fox (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS 3370 13tWT 7'f /G (- A IV APN LOT TRACT OWNER tillVLO f=A!EO Y ADDRESS 'S 3 )! O r36_?yT 7 tV1,5' C CITY )NA41,I&D I ,4e ZIP 9_17 S TEL.449449 8K/ 497/ 4"_5 APPLICANT DAIZ(D A I, -aTEL. __XW3 CONTRACTOR76q 57 S 0 ADDRESS CITY ZIP TEL. ARCRIENG/ DESIGNER ADDRESS CITY -�, ZIP TEL. OWNER -BUILDER DECLARATION I HSREBY AFFIW UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAN FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE:MIYCITYOR 0O NTY WMIOH REOIARFSAPERMOTO COMSTRUCL ALTER, IMPROVE, DEMOLISH,OR REPAIR ANI' STRUC- TURE, PRIOR TO ITS ISSUANCE. ALSO REOUWES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGHED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U - CENSE LAW (CHAPTER 8 (OOMMENCWO WITH SECTION 7000) OF DIVISION 3 OF THE SUSINESS AND PRO- FESSIONS ODDS) OR THATHE OR SHE 15 EXEMPT 7HEREFROMAND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7091.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO PENALTY OF NOT MORE THAN FME IA3ORED DOLLARS Baro).): 'ASE ASE WOR( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 704. RU51- ANO RROFES BUILDS CODE: THE CONTRACTORS LICENSE LAW OOHS NOT APPLY TO AN ERSELI � PRDPERTYMI910 BLILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORN HIMSELF OR HER6ELF Ofl THBO" MS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFEREDFORSALE IF, HOWEVER THESUIIDWG OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOUIP E- TIOM, THE OWNERBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 01, ASOWNER OF THE PROPERTY, AM EXCLUSNELYCONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 704, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LF CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND BAIDCONTRACrS FOR WON PROJECTS LWTHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACT TOMMs LICENSE LAW.). ❑ 1 ACM EXEMPT UNDER SEC - P.C. FOR THIS REASON b DATE -S-:?_Q0(2_OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM LENDER PENALTY OF PERJURY THAT H AM LICENSED UNDER PROVISIONS OF CHAPTER P MMMENONG WITH SECTION 7000) OF OMSION 3 OF THE BUSINESS AND PROFESSIONS OOOE, AND MY LICENSE IS IN FULL FORiCE 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. _ 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED 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 1 POLICY NUMBER L (THIS SECTION A® Nor BECOMPLIETFOOFTE PERMIT 6 FOR ONE HUNDRED DO -LAM ($100)ORLES% 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I I SHALL NOT EMPLOYANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WOfWERS' LY.MAPFNSATION PROVISIONS OF SECTION 37M OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. 1 ) DATE: APPLICANT e WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER DD TION TO THE AND CML FINES , D TO DAMAGES E HUNDRED TED FOR IN - DOLLARS ($tro,Oro), N ADDITION TO THE COST OF COMPENSATION, OAMAGEu" AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 FOR THE ERFOMUNDER PENALTY OFPERJURY THAT THERE MSACONSTRUCTION M,CIV AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3087, GV C ). LENDER'S NAME LENDERS ADDRESS I CERTIFY THAT i HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO 0041PLY 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 ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. 3 fJ f c� s PERMRT E (P ' E Com_ V O REOFPERT E CCJJ DATE PRESS FIRMLY APPLICATIO ll PERMIT P DATEy NUMBER 5e LO n I -TYPE OCC D- ATE � - Irl _ ad CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO, DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREAIVALUATION SFR7ADQA4EM Garage/Carport W Patio/va* LL Poovspa ZRe -Roof 0 Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U U U, J w 0 Z J a J Q _U 2 Q W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ! -•� �� "" ISSUANCE SMIP . ENERGY PICF y I'° �r 0 TrI ENERGY PERMIT >✓ ;w i r - ` `'✓�+ RETENTION FEE:'Jt.-L3t:+S PRE -ALT FEE: Tt, A?,�. TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATIO WHITE—Departmant Copy. YELLOW—Finance Cary. PINIK—ASS88Sor L OPy, LiULUMM RJ4J H0 %AW. U—crrrtMp —L s vapy