HomeMy WebLinkAbout12-271 ��__ CITY OF DIAMOND BAR � ✓
� DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES r`�
21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
��''"', BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE 7
o ADDRESS��'-8OW CYu-!� �� DATE'CATIO �j � � NUMB R v ��� #/C
a ISSUE TYPE OCC
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p ADDRESS�'SZ �Ql.1/L'�-� L�IZ ZONING SETBACKS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFIRM UNDER PENhLiY.OF PERNRY THAT t AM E%EMPT FROM 7HE CONTMCTORS LI• Gflfe J0/CefpOR.
W CENSEUWFORTHEFOLLOWINOREASON(SEC.7o31.68u51NESSANDPROFESSION5CO0E:ANYCITYOR (n
U COUI.JTYWHICHREWIRESAPERMI7TOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREVAIRANVSTRUC- W PatiWDeck
w TURE,PRIOR TO RS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED �W
� STATEMENT iHAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONSOP THE CONTRACTORS U� � .
� CENSE UW(CHAPTER Y(COMMENCING WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� POOVSPB
_ 0 iESS10N5CO0E)OqTiATHEORSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDE%EMP• (� . . .
V TION.AHY VIOUTION OF SECTION 7037.5 BY ANV MPLICANT FOR A PERMIT SU6IECTS THE AGPLICANT T0 Z Re-Rool
A CML VENALTY OF NOT MORE THAN FNE HUNORED DOLURS(i5a0).):
� ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � � COrt1R18fC18) -
Z WILL DO THE WORI(AND hIE STRUCTURE�S NOT INTENDED OR OFFERED FOR SALE(SEC.7ou,BU54 �J
� NESS AND OROiESSIONS CODE:7HE COMMCTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF �
VROPEHfY NTiO BUILOS OR IM7ROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HEHSELF OR �
Q THROUGHHISORHEROWNEM7lOVEES,PHOVIDED7HATSUd11MPROVEMEHTSAHENOTINTENDEDOR m
Q OFFEREDFORSALEIF,HOWEVER7ViEBUILDINGORIMPROVEMENTISSOLDWRHINONEYEAROFCOMPLE- ,
z TION,7HE OWNER-BUIIDER WILL HAVE THE BUR�EN OF PROVING 7HA7 HE OR SHE DID NO7 BUILD OR .
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W OI,ASOWNEROF7HEPROPEHiY,AAIEXd.USNELYCONTMCTM(iWfhILICENSEDCONTRACTORS
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W CENSE UW DOES NOTAP7LY TOAN ONMER OF A PROPERTV WHO BUILDS OR IMPROVES THEflEON,AND �
� 1ri1000NTMCTbFORSUCHPR0.1ECf5WITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECOHTRAG QUANTITY DESCRIPTION
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� DATE OWNER F-
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F UCENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRlA UNDER PENALTY OF PERIURY T}iAT I AM UCENSED UNDER PROVISIONS Of CHAPTER � . - � �
d Y(COMMENCINCi N7TH SECTION 7000)OF OIVISION J OF THE BUSINESS AND PROFESSIONS OODE,AND Z
X MY LICENSE IS IN FULL FORCE AND EFFECL m - � �
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECLARA710NS: Z � � -
O _IHAVEANDWILLMAINTAINACEF�IFICATEOFCONSENrTOSELF-INSUREFORWORKERS' _ �
Q COMPENSATION,AS PROVIDED BY SECTION 37000F THE UBOR CODE.FOR THE VERfORMANCE W��
Q OF THE WORK FOR HM1iICH 7HIS PERMI7 IS ISSUED. � � �
� _1 HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE;AS REdIIRED BY SECTION ' -
Q 370o OF THE UBOR CODE,FOR THE PERFORMMICE�OF THE WORK FOR WHICH THIS PERM1715
ISSUED.MV WORNFF..��S'a�PEHSATION INSUa�r�CE CARqIER�AND POLICY NUMBER ME: �CONSTRUCTION-
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Z 1 CERTIFV THA71N THE PERFORMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL
U' SHM.L NOT EMPLOY ANY 7ERSON IN ANY M/WNER SOAS TO BECOME SU&IECT TO THE �
� WORKERS'COMPENSATION LAWS OF CALIFORN11 AND AGREE THAT IF I SHOU�D BECAME INSPECTION FEE
SUBJECT TO THE WONKERS�COMPENSA7qN PROVISIONS OF SECTION J7o0 OF THE LABOR -�
� CODE,I SHALL FORTHN/1TH CO/APLY WITH/THO)SE PROVISIONS. �SSUANCE .� � D �
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DATE:�PPLICANT.
wWARNINO:fAILURE TO SECURE WORKERS'COMPENSATIOT N CAVERAGE IS UNUWFUL,AND.SHALL BE ENERGY P/C
� SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FWES UP TOONE HUNORED THOUSAN� ENERGY�PERMIT
DOLURS(i100.000),iN ADDITION TO THE COST OF CAMPENSATION,OAMAGES AS PROVIDED FOR IN
J SECTION 37oE OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES, � � � c-7
p� RETENTION FEE: G�� O C7
OCONSTRUCTION LENDINGAGENCY PRE-ALT FEE:
� 1 HEFEBY AFFIRM UNDER VENALTY OF PEFUURV THAT THERE IS ACONSTRUCTION LENOINO AGENCY
FOH TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMI715 ISSUED(SEC.3097,CIV.C.). �
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� LENDERS NM1E
F- LENDER'SADDRESS
w I CERTIfY THAT 1 HAVE READ THIS APPLICATION AND STATE�hUTTHE�BOVE INfORMATION IS CORRECT. TOTAL FEES . I •�
� I AGREE TO COMPLY N77H ALL CfTY AND CAUNTY ORDIN/JJCES AND STATE UWS REUTING TO BUILDING
� CONSTFUCTION.ANDHEREBVAUTHORIZEREPRESENTATNESOF7HISCOUNTYTOEFRENUPONhIE �
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� RECPT.NO. ' PAID BY VALIDATION
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