HomeMy WebLinkAbout14923 (17)DIVIONU HAK
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
ADDRIEE / 1� �,� �i Tis
ADDRESSr f `
APN LOT T Y TRACT
OWNER �.
ADDRESS S
CITY ZIP TEL
APPLICANT TEL
CONTRACTOEj�yF,
ADDRES$a–ViS Al
C � ZIPgr� TEL I ��3
ARC WENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERURY THAT 1 AM EXEMPT FROM THE CONTRACTORS UL
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSNESSAND PROFESSIONS CODE ANY CJTYOR
CCLOM V"CHI REOUIRESAPEWrTM O O NSTRUCTALTER IMPROVE DEMOUSH.OR REPAIR ANYSTRUC.
-TURF, PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE NOR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (CHAPTER I (COMMENCINGWITH sECT1ON 7000) OF DIVLSJON 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLKJ1Nr FORA PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW)l:
D LASOWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COMPENSATION.
WALL DO THE WORIL AND THE STRUCTURE IS NOT NTENOED OR OFFERED FOR SALE (SEC. 7044. BUS4
NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO SUERS OR IMPROVES THEREON. AND WINO DOES SUCH WORK HIMSELF OR HERSELF OR
TINOIOH HIS DR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF HOWEVER THE B ALONG OR IMPROVEMENT IS SOLD WITHIN ONE Y EAROF COUPLE.
TION. THE OWNERBUI DER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR
NPROVE FOR THE PURPOSE OF SALT.}
O LAS OWNER OF THE PROPERTY. AY WITH EXCLUSIVELY CONTRACTING LICENSED CONTRACTORS
TO CDNSTRUCT THE PADUECT (SEC. 70". BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U.
NS
CEE UW DOES NOT APRT TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR S" PROJECTS WITHA CVRRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS MCENSE LAW.),
D IAM EXEMPT UNDER SEG B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE G UG. NO. � A�
DAIS CONTHACTOfl� (�l�Nf'%(�F1�NR1 �7ni
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERAJRY ONE OF THE FOLLOWING DECLARATIONS
-I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFdNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37W OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE AS REQUIRED BY SECTION
37000E THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' NSATION INSURANCE CARRIER AND POLICY NUMBER ARE. -
6
CARWER ^ O
POLICY NUMBER ,..F fir' "-
(THSSECRDN W-MNOTSE03XLETEDOF THIS KMU 6 MRDNE WILREOOOJAM (6100)CRLES4
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY FEPSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAMS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUaJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
LODE. SINML THfW1TH COINPLY WITH THOSE PR SI�ONS.F�
IDATIEf
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINALM
PENALTIES AND CL F W ON
ES UP TO E HUNDRED THOUSAND
DOLLARS (iltw,(IoOt N ADDITION TO THE COSTOF COMPENSATION. DAMAOE3AS PROVIDED FOR N
SECTION 37000E THE LABOR CODE. INTEREST. AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCT" LENDING AGENCY
FOR THE PERFORMANCE OF RVA ICH THI�RMII ,IS ISSUED (SEC 3001, GV. C}
LENDERS NAME
LENDERS ADDRESS
1 CERTIFY THAT I HAYE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRI' AND COUNTY ORDINANCES AND STATE LAWS RE ATWG TO BUILDING
CONSTRUCTOK AND HEREBY AUTHORIZE REPRESENTATIVES OF TNS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPS TY FOR INSPECTION PURPOSES
PERAUTTEE NAME ( RIVT) f
SIGNATURE OF PERMITTEE V OA
PRESS
FIRMLY
APPLICATION Q 0J PERMPic
DATE �J �4l �� VV NUMBER
ISSUETYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR F-1❑
SIDE/SIDE STREET RW ❑
SIDE ❑
P POSED US
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NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADDIREM '
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QUANTITY DESCRIPTION FEE
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RETENTION FEE:
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WHITE--Depenment Copy, YELLOW—Fnenca Copy, PINK—,Assessor Copy, GOLDENROD—File Copy, GREEN—AppikarA'B Copy
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