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Home My WebLink About15012 (19)J� 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 TE ADDRESSAPN LOT ER EEC TRACT OWN ADDRESS LlniF� Cir ;hZc �y> Cmr1', ;►c�r�c�^C�2i1�ZIPL1�(,rjTEL�t 7, APPLICANT WLi l `'f�B-G. h! CONTRACTOR ,ADDRESS CITY ZIP TEL ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LL CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.6 BUSINESS AND PFIOFESS)ONS CODE. -ANY CITY OR COUNTY WHICH REWAFSAPU"T TOCONSTRUCT,ALTER IMPROVE, DEMOLISH, OR REPAIR ANY STRUG TURF, PRIOR TO ITS ISSUANCE, ALSO REQUAES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENM LAW DIVISION 3 (COMMENCING WITH SECTION 7000) OF DSION 3 OF THE BUSINESS AND PRO. FESSONS CODE) OR THAT HE OR SHE IS MI EXEMPT THERE FROM D THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VOLATI N OF SECTION 7031.6 BY ANY APPLICANT FOR A PEWIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (Ism)), D L AS ONNEROF THE PROPERTY,OR MY EMPLOYEES WITH WAGESAS THEW SOLE COMPENSATION, WILL DO THE Wow AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 70µ BUSI- NEID PE SS AND CODTHE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR TMPXXJGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFEREDiOR SALE G. HOWEVER THE BUILDING OR IMPROVEMENTISSOLD WITWN ONE YEAR OFCOUPLE. TICK THE OWNER-BURDER WILL HAVE THE BURDEN OF PROVING THAT RE OR SHE DID NOT BUILD OR IMPRDVE FOR THE PURPOSE OF SALE), D L AS OWNER OF THE PROPERTY, Al EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 704, BUSINESS AND PROFESSIONS COOS THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BU LOS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACOW RACTORIS) LICENSED PURSUANT TO THE CONTRA& TORS UCENSE LAW). D IAM EXEMPT UNDER SEG S. 6 P.C. FOR THIS REASON DATE O LICENSED CONTRA TORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 6 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE ANO MY LICENSE IS N FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _1 HAVE AND WILL MANTAN A CERTIFICATE OF CONSE. TO S.INSURiE FOR WORKERS• COMPENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERS• COMPCNSATON INSURANCE, AS REQUIRED BY SECTION 5700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CARRIER POLICY NJMSER "SECTION NEW NOT BE ODMP ETEDOF THE KAMIT6 FOR ONE MADAM DOLLARS (9100) OR LESS), I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON N ANY MANNER $O AS TO BECOME SUBJECT TO THE WORKERSCOMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT. WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECTAN EMPLOYER To CRIM WK M PENALTIES AND CL F WES UP TO ONE HUNDRED THOUSAND DOLLARS (3100,0001, N ADUITON TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FORIN SECTION 3703 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENONOAGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097. CIV. G). LENDER'S NAME LENDERS ADDRESS 1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING ODNSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE#RENTONED PROPERTY FOR INSPECTION PURPOSES. 1 + R (� P E � (PW r , SO RE OF PERMITTEE /1 DATE zF1 PRESS FIRMLY APPUCATIO (_ PERMIT O l p/C DATE—(Q NUM BE V ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ ROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM fn Garaga/Carport WPatio/Deck LL Pool/Spa 0 Z Re -Roof Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U k W ! c1, Lj 1 w 0 Z TD J IL U_ Z Q S U W M CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE nAf. SMIP ENERGY P/C ENERGY PERMIT MAY 2 1 211110 RETENTION FEE CITY PRE -ALT FEE: UILDIIqrj G E az PAND ViFery TOTAL FEES COMMENTS l RECPT. NO. 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