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Home My WebLink About15127CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 ,.. BUILDING PERMIT APPLICATION JOBSITE Ca414 ADDRESS APN LOT TRACT OWNER eri2 ADDRESS CITY zIP TEL zptp APPLICANT TEL. eii"Tl��O CONTRACTORA[16�t Vo ADDRESS 0 CITY ZIP , TEL ARC NG! DESIGNERGG1 ADDRES CITY ZIP( TEL a OWNER -BUILDER DECLARATION I HEREBY AFFIRM LINDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI - GENES; LAW FOR THE FOLLOWNG REASON (SEC.7MIA BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WIUCH REOIMESAPERMT TO CONSTRUCT,ALTER IMPROVE, DEMOUSH.OR REPAIRANY STRUC- TURE PRIOR TO ITS ISSUANCE, ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L4 CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO- FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO ACNIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): ❑ L ASOWNER OFTHE PROPERTY IDA MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70AA. BUSI- NESS AND PROFESSIONS OOO ' THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEROF PRGPERTY WHO BUILDS OR IMPROVES THEREON. ANOYMO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE IF,HOATWFkIHE SUMDNGOR IMPROVEMENT IS SOLD WTTHINONE YEAROF COMPLE• TION, THE OWNE"UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ L AS OWNER OF THE PROPERTY, AI EXCLUSYELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOT APPLYTOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THERECN. AND W11000NTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW) - O 1 AM EXEMPT UNDER SEC. S. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HM LIN DE AFFIRDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER I (OOMMENCNG YAM SECTION 70001 OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY 57 DCENSE 6 N FU FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE CONTRACTOR _ +, I WORKERS' COMPENSATION DECLARATION / 1 NEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: i I HAVE AND WALL MAINTAN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 7700 OF THE LABOR CODE, FOR THE PERFORMANCE 1 OF THE WORK FOR W'HK21 THIS PERMIT IS ISSUED. -I HAVE AND WILL MANTAN WORKERSCOMPENSATION INSURANCE, AS REOURED BY SECTION 71000E TMELABORCODE.FO THE PERFORMANCE OF THE WORK/On WHICH THIS PERMIT IS I SSUED. A(Y RS' P ATL�y�SU CARRIER 'POLICY NUMBERARE:' , CARRIER / p POLICY NLWar a t1M SECTION NEEDNDTBE CMIFLCTEDOFTTIE PEPMT IS FOR ONE RM)RED00LLAM (S100)ORLES% (CERTIFY THAT LATHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I i SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOASTO BECOME SVBJECTTO THE j WORKERS' COMPENSATION LAWS OF CAU A. ANO AGREETHATWISHOULDBECOME SL18JE �OTiE WORKERS COMPENSATKNN OVIS OF SECTION j CODE. I SMALL FORTHWITH COMPLY WITH IT ► (.i ) DATE., APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBOECT M EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (3100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN J SECTION 3705 OF THE LABOR CODE. INTEREST. AND ATFORNEYS FEES. CONSTRUCTION LENDING AGENCY 1HEREBY AFFIRM UNDER PENALTY OFK FDA W THAT THERE ISACONSUED(SEC LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG SWI, CIV. C). 7 LENDERS NAME LENDETI'S ADDRESS C I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE NFORMATION IS COMECL U 1 AGREE TO COMPLY WTTN ALNA L CITY ACOUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING rL CONST RUCTIO AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE s ABOYEdNENTI O PR R INSPECT( I V SES ��n = PERM N EIPRNT) L n Sq DA k L (D PRESS FIRMLY APPUCATIO I PERM (l, PCOO DATE NUMBER 1� ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE ..-. NO. DWEL. I— NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT.' FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM 07 Garage/Carport W Pallo/DeCk ILL PooVSpa ZRe -Roo( 0 Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE O \ v U W W _ _ O O C) Ta 14Z J O G. U 3 z d 4 U L 0 1{-o (7 d za CONSTRUCTION ! PLAN REVIEW ELECTRIC PLUMBING MECHANICAL �'/ • INSPECTION FEE �, �Uv ISSUANCE 00"970 SMTP t ENERGY PIC t M - ENERGY PERMIT 41 I �- L LV O v RETENTION FEE: e,2 P E• LTF,E� / f iT-v (1T:' TT A r/1* -TT. ✓ A_++ I ��LL{{ JO QT TT T-, .7.. .._ Ll TOTAL FGEjE/� (� oto �nN(�� (`�/J� -3 zV" C MENTS ` RECPT. NO. PAID BY VALIDATION WHITE--DepartmOnl Copy, YELLOW—Finenoe COPY- PINK—AMSSOf L:OPy. UUL.MLNMVv PCL. t7Y. �• Qc F4VI w� ' & wFY