HomeMy WebLinkAbout10250CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
�rC 21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
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APPLICANT TEL.
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ADDRESS
CITY ZIP TEL
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM LANDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF
CFNSE LAW FOR THE FOLLOWING REASON (SEG 70.71.E BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHK3N REWIRESAPERAIIT TO CONSTRIJCTALTEFL IMPROVE. DEMOUSKCAR REPARANYSTRUC
TUBE. PRIOR To
RO REO
S ISSUANCE, ALSO, THE APPLICANT FOR SUCH PET TO FRE A SIGNED
STATEMENT THAT he
W
OR SHE IS LICENSED PURSUANT TO THE PROYISHS LL
OF THE CONTRACTORS
CENSE UW (GIAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEAtLEGED EXEMP•
TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICMIT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE NNORED DOLLARS ($Soo).):
O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WALL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 7044, BUSI-
NESS
USHNESS AND PROFESSIONS LODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, MID WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH IIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH W PROYEMENTSARE NOT INTENDED OR
OFFERED FOR SALE IF.HOWEVEFL THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION. THE OWNERBUILDER WILL RAVE 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, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC 7OA4. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WINO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHAOONTRACTOR(S) LICENSED PURSUANT TO THE OONTRAG
TORS LICENSE LAW ),
O 1 AM EXEMPT UNDER SEG 8. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DfCLARATr0N
I HEREBYAFFRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
F (COMMENCING WfTH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CUSS UC. NO.
LUTE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLIOWNG 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.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS RECL RED BY SECTION
3700 OF THE LIBOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
&&SUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
POLIOYNULIBER
(THS SECIION REED NOT BE CDNPLETED OF THE PERMIT IS FOR ONE HUNDRED DOI1AAS (&100J OR U S4
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SMALL NOT EMPLOY ANY PERSON N ANY MANNER BOAS TO BECOME SUBJECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE APPLICANT:
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNL A'FUL. AND SWILL BE
SUBJECT AN EMPLOYER TO CRIMINAL M
PENALTIES AND CL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (11100,000& IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR N
SECTION 3700 OF THE LABOR CODE. NTERESL AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERNRY THAT THERE IS A CONSTRUCTION LENOWG AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3007, CIV. C).
LENDERS NAME
LENDERSADDRESS
I CERTIFY THAT 1 WIVE READ THIS APPLICATION AND STATE THAT THE ABOVE WFORMATON IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDNANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE4AENTIONED PROPERTY FOR INSPECTION PURPOSES
PERMITTEE NAME (PRINT)
R4?
SIGNATURE OF PEF1M7EE H DATE' �-
0-c
PRESS
FIRMLY
APPLICATION
PERMIT
P/C
DATE
NUMBER O
X
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDEISIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL NO.
UNITS STORIES
iEROC
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREANALUAT10N
SFR/ADDIREM
Garaye/Carpon
W
PabolDea
Li
Pool/Spa
ZRe
-Root
0
COrnmemial
-
m
1
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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U
0
W
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L7
2
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
— I.
SMIP
ENERGY PIC
ENERGY PERMIT `
RETENTION FEE:
PRE -ALT FEE.
TOTAL FEES
COMMENTS
RECPT. NO. PAID BY
VALIDATION
WHITE--DepaAment Capt', YELLOW—Finance Copy. PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—ApplicWs Copy
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