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Home My WebLink About14985Uri 4 0 S r•�y h 533 S2 cc O lj¢N O C2 w tL en X� W O N Z� Q P_] ii LJ.. ¢J W d O a E 1— R 0 DO DO Q V_n J� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 PRESS (909) 860-3195 Fax (909) 861-3117 BUILDING PERMTP APPLICATION FIRMLY JOBSITE ADDRESSC 15,5 KGc Rte( APN LOT TRACT OWNER ADDRESS CITY ZIP TEL APPLICANT TEL CONTRACTOR N� t Nn ADDRESS CITY Z TEL ARCFUEN DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L1. CENSE LAW FOR THE FOLLOWING REASON (SEC. 7071.6 BUSINESS AND PROFESSIONS CODE' ANY CITYOR mLlifY WWIICFI REOIIIRESA PERIMITTDODNSTRUCT ALTEILIMPROVE DEfAOUSItOA REPNRANY STRUG TUBE PROq TORS ISSUANCE A150 REW WES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (C3APTER o (COMMENCNO WITH SECTION 7000( OF DIVISION 7 OF THE BUSINESS AND PRO. =S= OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. MPI VIOLATION OF SECTION 70113 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVIL PENALTY OF HOT MORE THAN FNE HUNDRED DOLLARS D LAS OWNER OFTHE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DD THE WORN, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSF NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY To AN OWNER OF PROPERTY W`10 BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFF73iED fOR SALE tF,HOWEVER THE BUILDING OR IMPROVEMENTIS SCUD WITHIN ONE YEAR OF COMPLE- TION, THE OWNERARLDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE "THE PURPOSE OF SALU O L AS WAGER OF THE PROPERTY, AM EXCW3NELYCONTRACTNO WrrM LICENSED CONTRACTORS to CONSTRUCT THE PROJECT (SEC, 7044, BUSINESS NTD PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WTTHACONTRACTMS) LICENSED PURSUANT TO THE CONTRAC. TORS LICENSE LAW), AM EICEMPf UNDER SEG B. a P.C. FOR TMS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I NERERY AFFIRM UNDER PENALTY OF PERAM TWT IAM LICENSED ODER PROVISIONS OF CHAPTER I (COMMENCING WITH SECTION 7000) OF OMSON 3 OF THE BUSINESS AND PROFESSIONS CODE AND W LICENSE IS N FULL FORCEAND EFFECT. �/ LJCENSE CU LIC. NO, 0 DATE s CONTRACTOR WORKERS' COMPENSATION DECLARATION I HERESY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOUDWNG DECLARATIONS: _I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFNSUAE FOR WORKERT COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CCOE FOR THE PERFORMANCE OF THE YOM FOR VMCHTHIS PEP$M IS ISSM. .. I _1 HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REWIRED BY SECTION S7000F THE LABOR GOOF, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE- CARRIER RECARRIER POLICYNIM9ER - LRP$ SECTION NEED NOT BEOCAPLETEDCFTHE PERNYT13 FOR ONE HI-NDIMDOLLARS IS1001 ORIESSS L CERTFYTFUT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS 70 BECOME SUBJECT TO THE WORKERS* COMPENSATION LAWS OF CALIF(1RMA ANDA EE7WTIFISHDUDBEOOME------ SUBJECS* TO THE WORKERS COIAP£N$ATION PROMS OF $ 00 OF THE LABOR COOEISHALL FORTnrWiTNCWPLY WITH INOSE P 5 DATE: r� APPLICANT. / WAPNNC FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANO CML FNES UPTO ONE HUNDRED THOUSAND DOLLARS (SIo0.000t N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 77060E THE LABOR CODE, INTEREST, ARU ATTORNEY'S FEES. - - CONSTRUCTION LENDING AGENCY 1 HERESY AFFIRM UNDER PENALTY OF PERAJRW THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED (SEC. 3W7, CIV C.). LENDERS NAME LETNDER'SADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CRY AID COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE#JE/NTIONED PROPERTY FOR INSPECTION PURPOSES j �h u 7 ��GU1- Fes! ! � � ov SI TURE OF EFWITTEE �� DATE APPLICATIONV�j PERMIT PIC DATE NUMBER A ISSUE TYPE OCC DATE CONST, GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDESTREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFRIADD/REM Garage/Carport W Patlo/Deck LL PooVSpa Z Re -Roof Commercial - m Valuation AOI.ARFA QUANTITY DESCRIPTION FEE Q , U Cr F- U LU (i Z DD a LGL.620 aC l oC,; r U Q W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING ' - - MECHANICAL 7!1 w INSPECTION FEE ---- �. �N - ---'-'-- ---- ISSUANCE SMTP a 2000 ENERGY PIC , ENERGY PERMIT - I1 Y OF Ult i L RETENTION FEE. MILDING AND r PRE -ALT FEE: TOTAL FEES >7 (/ COMMENTS RECPT. NO. PAID BY VALIDATION WHITE --Department Copy, YELLOW --Finance Copy, PINTS—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicam's Copy