HomeMy WebLinkAbout15047CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUELDI NG PERMIT APPLICATION
JOBSITE
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APN LOT TRACT
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CITY
YCITY DIA,,,,I l,.,r ZIP Si� TEL 909 .'79 Y3,U
APPLICANT-)AyJBr A7eN1rYyd?_ TEL $167015'03'7
CONTRACTOR Q_ lJ IA 11 floc r ti�
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFF04 UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7071.6 BUSINESS ANO PROFESSIONS ODOG:ANY CITYOR
COUNTY VI4KN REQUIRES APERIM TO CONSTRUCT,ALTER. IMPROVEDEMOUSH, OR REPAIR ANY STROP
TU1RE PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FEE A SIGNED
STATEMENT TWAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L4
CENSE LAW (CHAPTER 6 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO•
FUSION$CODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEIEMP-
TION.ANY VIOLATION OF SECTION 7041,6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACRALPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (25W).}
U LAS OWNER 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, BUST.
NESS 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
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED CR
OFFERED FOR SALE IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLDYM41NONE YEAR OFCOMPLEE
IDN, THE OWNEROUILDER WILL HAYE THE BURDEN OF PROVP/O THAT HE OR SHE 00 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY, AM E%CLUSNELY CONTRACTNO WITH LICENSED CONTRACTORS
TO CONSTRICT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U -
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHOCOHTRACrS FOR SUCH PROJECTS WITNA CONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.).
O 1 AM D(EMPT UNDER SEC B. I P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIFM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (COAMEHCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS c 9 UC. NO.
DATE I I 1 CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HERESY AFFTM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DE TONS
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELJ:4NSU FOR WWORKERS'
COMPENSATION. AS PROVIDED BY SECTION 4700 OF THE LABOR CODE, F EPERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILMANTAN WORKERS, COMPENSATION INSURANCEAS RECUR YSECTON/
37000E THE LABOR COLE FOR THE PERFORMANCE OFTHE WORK FOR THISPERMITIS
ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLI ' NUMBER ARE:
CARRIER
POLICY NUMBER O S / J O
(TFLSSLDTI7NNEED NOT BECOMPETFDOF71E POW S FOR OrE RLI (SIODIOiL
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FCR LVIIICHTHIS SISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY
MANNER SOAS TO BECOME SUBJE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHmAD BECOME
SUBJECT TOTHE WORKERT COMPENSATION PROVISIONSOF SECTION 47000E THE LABOR
CODE I SHALL FORTHWITH COMPLY WITH THOSE PP S
DATE: �' / o O APPUCAM:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ({700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 4706 OF THE LABOR COOS INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A OONSTRU1CrI N LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 4097, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATOR AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY 70 ENTER UPON THE
ABOVE.MENTIONFD PROPERTY FOR INSPECTION PURPOSES.
J A,/1 c -x '45,cArrv,-' �
PERUR7EEP
SONArUREO ERMITTEE DATE
PRESS
FIRMLY
APPLICATION l PERMIT 5011 P/C
DATE NUMBER J U #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDESTREET RW ❑
SIDE ❑
PROPOSED USE
J
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
to
Garage/Carport
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Valuation o ADJ.AREA
QUANTITY DESCRIPTION FEE
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INSPECTION FEE
ISSUANCE
SMIP CITY DE DIAM �-
ENERGY P/C T2I ;�, T)TrTr: AVIV Ll SA-- FL iI 1y
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES 3 0
COMMENTS
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RECPT. NO. PAID BY _ VALIDATION
WHITE—Department Copy, YELLOW--FnanCe Copy, PINK—ASsessor Copy, GOLDENROD—File Copy, GREEN—AppliCAnt'S Copy