HomeMy WebLinkAbout15023 (8)CITY OF DIAMOND BAR
DEPART14ENT OF COMMUNITY & DEVELOPMENT SERVICES
e 21660 E. Copley Drive Shite 190
(909) 860-3195 Fax (909) 861-3117
BUILEIING PERMIT APPLICATION
JOBSITE
ADDRESS ( 5 Z / x/
APN LOT- TRACT
OWNER 1
ADDRESS 1 .D
C 4fL1,16,A9 :60 IP TEL C3
APPLICANT TEL
CONTRACTOR C y
ADDRESS L
CITY ZIP TEL
ARCVUENGI
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFBW UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS T. .
CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSNESSAND PROFESSIONS CODE ANYCITYOR
COUNTY WHICHREOUIRESAPEWARTO DONSTRUCT.ALTER MPROVE DEMOL:St OR REPAIR ANY STRUC-
TURE. PRIOR TO RS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PEAWT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (OWTER a (COMMENCING WITH SECTION 7000( OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROMAND THE BASIS FORTHE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 70316 BY ANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANTTO
A CIVIL PENALTY OF HOT MORE THAN FIVE HUNDRED DOLLARS
CIL AS OMNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSI-
NESS
USTNESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR
THROIXN HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENCED OR
OFFERED FOR SALE IF.LOWEVER. THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COUPLE -
TION. THE OWNERaULDER WILL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR
"PROVE FOR THE PURPOSE OF SALES
CI L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 70N, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LF
DENSE UW DOES NOT APPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO
CONTRACTS FOR SUCH PROJECTS WI TH A CONT RACTOR(S) LICENSED PURSUANT TD THE CONTRA,
TORS LICENSE LAW.).
O IAM EXEMPTUNDER SEG B. 3 P.G FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
THEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
S ICOLBMENDNDIVISION 3 OF THE BUSINESS
O WITH SECTION 7000) OF DESSAND PROFESSIONS CODE AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CUSS LIC. NO.
DATE �' CONTRACTOR WORKERS' COMPENSATION DEC ON
I HEREBY AFFIRM UNDER PENALTY OF PERJURY CNE OF THE FO110 NO DECLARATION /
I HAVE AND WILL MANTAN A CERTIFICATE 6F COHSE N1 TOS YSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LIBOR RTHEPERFO
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WH CH( THIS PERMIT IS
155UFA W WORKER ' COMPENSATION INSURANCE CARRIER AND
POLICY NU MBE
CARRER
POLICY NUMBER
(D4SECnoNWMNOTSECLAPLETEDOFT)EPF WISFORONEI4.NORFD RI )DRLE551
I CERTIFY THAT N THE PERFORIMNCE OF THE WORK FOR WHICH THIS PERMIT
SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CMIFORNIA. AND AGREE THAT IF I SHO LtD BECOME
SUBJECT TO THE WORKERS COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
COOE.1 iORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE APPLICATIT: L
WARNING: FAILURET SECURE WORKERS' COMPENSATION COVERAGE U WFIA, AN 5 BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP T HUNDRED OUS iD
DOLLARS(i100.000). N ADCITIONTO THE COST OF COMPENSATON.D ASPROVO N
SECTION 3706 OF THE LABOR CODE NTEREST. 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 (SEG TORI. CIV. G).
LENDERS NAME
LENDERSADDRESS
1CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELAY WG TO BUILDING
CONSTRICTION. AN HERESY AUT OWE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION FVRPOSES.
PERMKTTEENAME(PRI" I t�
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SNGNATUREOFp EE DATE
PRESS
FIRMLY
APPLICATION vO PERMIT PIC Q 6751a
DATE NUMBER #
ISSUE �jj_�1 ,{ TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
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SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF AD REA/VALUA
SFR/ADOIREM
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Valuation ADJ.AREA
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RETENTION FEE:
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TOTAL FEES r7o< , Q
COMMENTS
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RECPT. NO. PAID BY VALIDATION IL
WHITE Ktment Copy. YELLOW—Fliance Copy, PINK—Assessor Copy. GOLDENRODL-File Copy. GREEN—Appiicant's Copy
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