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HomeMy WebLinkAbout13395r 0 cc I W1 lL J u°C1 O OC Q. TSW S I- LIIJ CL 0 m a Cr 3 CITY OF DIAMOND BAR DEPARTMENT OF COMM Y &, D ELOPMENT SERVICES CK . 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 oWipA G PERMIT APPLICATION JOBSITE ADDRESS APN LOT TRACT OWNER ADDRESS CRY ka? APPLICANT TEL.�S CONTRACTOR ADDR S E CITY ZIP TEL 371,! X ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS U- CEHSE LAW FOR THE FOLLOWING REASON (SEC. 70313 BUSNESSANO PROFESSIONS ODDS: ANY CRY OR COUNTY WHICH REOURESAPERMTTO CONSTdUCLALTEIL IMPROVE, DEMOLISH. REPAIR ANYSTnUOG TURF. PRIOR TO ITS ISSUANCE ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL CENSE UW (CHAPTER 0 (COMMENCNO 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 THEALLEGED EXEMP- TION. ANYVMAT04 OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANT TO A CIVIL. PENALTY OF NOT MORE THAN FIVE /HARED DOU AAS (i500).r D LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES ASTHEIR SOLE COMPENSATION, WILL DO THE WOROC AND THE STRUMRE IS NOT INTENDED OR OFFERED FOR SALE (SEG 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 WES SUCH WORK HIMSELF OR HERSELF OR TWO" HIS OR HER OWN EMPLOYEES, PROVIDED TWIT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF,HOWEVER THE SUILDRIG OR IMPROVEMENT 19 SOLD WITHIN ONE YEAROFOOMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALLE). D L AS OWNER Of THE PROPERTY. AAL EXCLUSIVELY CONTRACTNO WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 70". BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR MOVE PRS THEREON, AND WHOCONTR . FOR SLICH PROJECTSWITH ACONTRACTOfgS) LICENSED PURSUANT TO THE CCNTRAG TORS UCENSE LAW.). O 1 AM EXEMPT ANDER SEG B. 5 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HERESY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED LANDER PROVISONS OF CHAPTER 5 (COMMENCING WITH SECTION TOGO) OF DMSION 7 CF THE BUSINESS AND PROFESSIONS WOE, AND W LICENSE 6 N FULL FORCE AND EFFECT. ('A LICENSE CUSS & LIC. NO. / -706 ] O 6 -507 DATE - Li -14 CONTRACTOR_MjL_ L {4�,_ . WORKERS COMPENSATION DECLARATION AAAA I HEREBY AFFIRM UNDER PENALTY OF PERURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFNNSURE FOR WORKERS COMPENSATION, AS PRDVIDEO BY SECTION WOO OF THE LABOR COOP, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PER N" IS ISSUED. 1 HAVE AND WILL MANrAN WORKERS COMPENSATION INSURANCE. AS REOUMED BY SECTION 77000E THE LABOR OODIF FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS CARRIER • P /1 g1tN gANCE CARRIER AND POLICY NUMBER ARE POLICY NUMBER� n��)`�� (OL$ SECTOR NEEDNOT BECOAPILTTDOFTFE PERMIT IS FOR DNEM.,TDREDMLIAM (U001ORLM I CERTIFY THAT N THE PERFORMANCE Of THE WORK FOR WHICH MIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUWECT TOME WORKERS COMPENSATION LAWS OF CALIF(OiRUA ANDQIEFOTTT ULD BECOME SLRACT TO ME WORK ERS COM PENS NSOF MELABOR M COMPLYTROs OATS: �-��APPLICAM: WAR N0, FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN M EMPLOYER TO CRIMINAL PENALTIES AND CL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100.IXXI , IN ADDITION TO ME COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF ME LABOR CODE, INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 NEREBYAFFOW UNDER PENALTY OF PERJURY THAT MERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF ME WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3o97. CN. G). LFNDEITS NAME LENDERSADDRESS I CERTIFY THAT 1 HAVE READ THIS APPLICATIONAND STATE THATME 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 AOOVE1 10NED PROP FOR INSPECTION PURPOSES. Ou PERM )R NA R S ` q - `/ n SIGNATUREOF -t- PERMITTEE DA EPE/\FMITTEE `V DA E PRESS FIRMLY APPLICATION PERMIT I�;� P/C DATE NUMBER I # ISSUE ,,�.� TYPE OCC --II DATE —liJ "� 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. AREA/VALUATION SFR/ADD/REM Garage/Carport WPatia/Deck LL POOI/Spa ZRe -Roof Commercial E5 m Valuation ADJ.AREA OUANTITY DESCRIPTION FEE J Q U E¢ U J W E7 F GST 6 J U Z Q S W CONSTRUCTION PLAN REVIEW ELECTRIC F P BI - MECHANICAL INSPECTION FEE 7 ISSUANCE �• SMTP ��1T�.1'�4; ENERGY P/C V �s ENERGY PERMIT RETENTION FEE.- EE:PRE-ALT PRE-ALTFEE TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE --Department Copy. 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