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HomeMy WebLinkAbout13395 (7)In IN No (LLA W F-• Z Cn I W1 3 CITY OF DIAMOND BAR DEPARTMENT OF COMM Y &, D ELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 oWigA G PERMIT APPLICATION JOBSITE ADDRESS APN LOT TRACT OWNER ADDRESS CRY ka? 140 3 DO APPLICANT TEL.5 :23 S CONTRACTOR O ADDRESS *- CITY ZIP TELA7,A I X ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS 11. CENSE LAW FOR THE FOLLOWING REASON (SEC. 70313 BUSNESSANO PROFESSIONS CODE: ANY CRY OR COUHTYVM MREOLORESAPERL/ITT000NSTIUCLALTEILIMPROVE,DEL*)USKORREPAIRANYSTRRIG TURF. PRIOR TO ITS ISSUANCE ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI. CENSE UW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 5 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP- TION. ANYVMATON OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANT TO A CIVIL. PENALTY OF NOT LORE THAN FIVE /HARED DOLLARS O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES ASTHEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE is NOT INTENDED OR OFFERED FOR SALE (SEG 7047. BUSI- NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND W/OWES 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 BUILDING OR IMPROVEMENT IS 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 SALE). O L AS OWNER Of THE PROPERTY. AAL EXCLLISNFLY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 707, BUSINESS AND PROFESSIONS COVE THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR MOVE PRS THEREON, AND WHOCONTR .FOR a"PROJECTSWITH ACONTRACTORS) 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 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 5 (COMMENCING WITH SECTION 7000) OF DMSION 7 CF THE BUSINESS AND PROFESSIONS WOE, AND MY LICENSE 6 N FULL FORCE AND EFFECT. ('A LICENSE CUSS & LIC. NO. / -706 ] O 6 -507 DATE - L - NCDNTRACTOR, � D L {� . WORKERS' COMPENSATION DECLARATION ... I HEREBY AFFIRM UNDER PENALTY OF PERURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF4RSURE FOR WORKERS COMPENSATON, AS PROVIDED BY SECTION WOO OF THE LABOR COOP, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 HAVE AND WILL MANrAN WORKERS COMPENSATION INSURANCE, AS REOUIRED BY SECTION 77000E THE LABOR CODA FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS tSSUED.CAFREOUP gANCE CARRIER AND POLICY NUMBER ARE POLICY NUMBER n��)`�� (w SECTION NEEDNOT BECOMPLETIDOFTHE PERMIT IS FOR CNERMI tFDMLLAM (U000ORLM I CERTIFY THAT N THE PERFORMANCE Of THE WORK FOR WHICH TOS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUWECT TO THE WORKERS COMPENSATION LAWS OF CALIFORMA ANDQIFCTTT ULD BECOME SUBJECT TO THE MANICERS COMPENS NSOF THE LABORSUBJE TR COMPLYTEAS OATS: �-��APPLICAM: WARNING, FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL M I L PENALTIES AND CL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTOR 5700 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 FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097. CN. G). LFNDEITS NAME LENDERSADDRESS I CERnI YTHAT 1 HAVE READ THIS APPLICATIONAND STATE THATTHE 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 AOOVENMEMIONED PROP FOR INSPECTION PURPOSES. Ou PERM )R NA FS S ` q - n SIGNATURE OF -t- PERMITTEE DA EPERMITTEE DA E `17 PRESS FIRMLY APPLICATION PERMIT I�� 1,33 P/C DATE NUMBER1 # ISSUE TYPE OCC --II DATE —liJ "� CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR p SIDE/SIDE STREET RW ❑ SIDE p PROPOSED USE NO. DWEL NO. NO. . UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM (j) Garage/Carport WPatia/Deck LL POOVSpa ZR"oo1 Commercial m Valuation ADJ.AREA OUANTITY DESCRIPTION FEE J Q U E¢ U J E7 F GST 6 J .a.1 U Z Q S W CONSTRUCTION PLAN REVIEW ELECTRIC F P BI - MECHANICAL > ��J��I INSPECTION FEE 7 ISSUANCE7. V" �• SMTP ��1(�.1'L4; F ENERGY P/C V _ �s ENERGY PERMIT RETENTION FEE., PRE -ALT FEE TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE --Department Copy. 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