HomeMy WebLinkAbout16103 _�F.�� CITY OF DIAMOND BAR
� DEPARTMBNT OF COMMLTNITY&DEVELOPMENT SERVICES
2156t?B.Capiey Ihive Seute 194
� (909)86Q-3195 Fax(909)861-311'7 P,RESS
�'A�` BUILDING PERMI'I'APPLICATION �t.SS i C.- � Z ;' FIRMLY
y�, JdBSITE � APPLICATION (; PERMIT f - P/C
o ADDRESS__��`?����'7�i.)� DATE � - �-�1 NUMBER ' �`�� #___,�_
� ISSUE IYPE OCC
APN 14T �-'Q� TRACT .S'X.�G'T DATE CON9T. GROUP
� OWNER MC �
ADpRESS__jJ' � C+'I 1!'M'l��- ZONING SETBACKS
�W CiTY , j fivt ZtP'�z� TEL.'�'�ry-?�` O R��RT RW ❑`
APPLICANT ,_����cMC. TEL. �� SIDElS1DE STREET RW ❑
� CONTRACTOR SIDE �
ADDRESS��
� ,,, r PRQPOSED USE__
� C1N 1�r.x�„__ ZiP �2biL TEI. —
ARCH/ENG/ �_`
DESIGNER Mt4f�� �r'l,+S.� �' /f«i S+�L <
� ADpRESS��.S:� I1 — NO.DWEL. NO. NO.
� UNITS STORIES BEDROOMS
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rts DESCRfPTIdN SQ.FT. FAGTOR PSF ADJ.AREANALUATIdN
p� OWNER-BUIIDER DECLARATION SFRlA6DJREM
p 1 HEREBV AFFlRM UNDER PENALTY OF PEfUURY TNAT I M/E%EMPT FROM THE CONTFiACTORS!,I• �,adfage/C�dfpOff
� CEIISEUWFORTHEFOl.i�C�4MMGREA&ON(SEC.T68i.58U5WE55RNOPftt}FESS�ttStt%�DE:ANYCITYOR (j}
COtINTVMMICHREOUtRESAPERMffTOCON9TR�CT,AL7ER.IMPROVE,DEMOUSH,ORREVAIRANYSiRtIC, W PaI70/DBCK
TURE,PRIDR TO ITS 139UANCE,i1L54 REOUIRES TME APPLICANT FOR SUCH PEf1M1T TO FIIE A SIGNEp W
� STATEA4ENt TXAT HE Oft 5NE!S IICE+Y5E4 PURSUANT T4?}1E PROV7SIOF7S OF THE CbNTRACTORS Li�
CENSE UW�CHApiER i((%MIMENCIN4 WITH SECTION 7000)OF DIVISION 3 pF`7HE BUSIN6SS AND PRo- u' Po4�Sp9
fE55qNSWDE)OHTHATHEORSHEISE%EMPTTHEREFR0IAAN�THEBASISFaRtHEALLEGEDEXEMP� (�
� TIIXi.ANYYN,7lAT10NOFSFGTION703t.iBYAM'AAP��AN7FORAPERMITSl1&1ECTSTHEAPPLIGANiTO Z qe-Root
� A CML 7ENALTY OF NOT MORE THAN FNE HUNORED DOLLARS(1500).):
� �{,�OW!lER�FTHEPPQFERTY,OFMYEMPLQYEESWITHWR6ESASTNElfl50tECAMPENSATI4N, CS {,`p�mgtCidl
WILl00 7NE W6RK,tN6 7"HE STRUC7URE�S NOT iNTEN6ED OR OFFEREO FOfl SALE(SEC.7044,8U5b J
� � NESS AND PqOFE5SWN3 fXIDE:TME CONTMCTORS IICENSE LAW�OES NtlT APPL�TO AN OWNER OF �
pROPERN VA�K18UkD50fi NIPf�VE3 THEflEOM,AN{}YMO OdES 5UCM WORK HIMSELFQR HERSEtF OH
CC T7iROUdiH�SOflHEHOWNEMPLOYEE5,Pf10YlUEGT1IAT$UCNIMPROVEMENiSAqENOTM7ENbE�OH m
QOFFEpEDF6H3KEIF,H4WEVERNEBU��DINGORIMPRbYEMENTIS50LDW17HINGNEYEAROFCUMPI,E- �
� TqM,Tt�UWNEft�BUILDER Witi NAYE THE BUR�T!OF PRDYUiG TNhT HE OR SNE DID NOT BUItD OR
IMPRQVE FOH LHE PURPO:iE OF SALE�.
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� ro cqNs�raucT Tt�E aaa�ci ts�c_'rou.�s�wEss u�ro aao�ss�oras ceoe:THe coNtRacToas u� Valuation AOJ,AREA
UJ CENSELAWpOESNO�APPLYt4ANOWNERQFAPROPERTYWI�LL�BVtLpSOqMPROVESTHEREON,ANp �` ' . "
� NM1fOCONTRACTSFORSUCHPRQJECTSW7TNACONTMCTOR(5)UCEN5EDPURSVANT-OTHECONTRAG Q(JANTtTY DESCRIPTION FEE
�� 70RS IiCENSE tAW.).
QO i tAt EXEMPT UliOER SEC.` „ B.d P.C.FOR 7HE5 REASON Q
3 �
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4ATE OWNER __ ,,.�,,,_ U�����
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�+C[ �iGENSED CONTRACTOAS DEGViRA7I6N W
Lr (HEflE9Y AFFIRAt LWDER PFiNF1TY OF PEFUUiiY iNAI i AM itCENSED UPiQEN AROYiSiQMS O�GtfAR7ER u. `
� A tCOMMENCWO WITN SECi'qN 70ooj OF DPdIS�ON�OF THE BU51NF55 ANU PROFESSIONS CODE,AND 7
}C MV LICENSE IS IN FULL FqqCE AND EFFECT m � ��
ttl �^�
Q UCENSE CLASS� LIC.NO. 7 � � T�
wDATE,�.�....:�...�- CPNTRAC70fl . ►n� d _...— ..� ..�—._
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� i HEflE6Y AFfiFU1 VNDER F£NN.TY OF PERR1flY ONE aF TN'e fOGI�WING DECLARATlONS: Z v
� INMEANqWILLMAINTAINAC£flTIfICAiEQFCONSENTTOSELF-INSVREFOF1R40RKERS' a � �
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~CJJFiPENSA7qN,AS PRi;ViQ�b BY 56CT�(M7310o pF�HE I.hBOR CODF,FOR 7HE PEflFORMANCE IU
OF THE WQR1(FOq wHICM TH15 PEPMIT IS 155UE0. �
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� .,,,�,.,INAVEANpWILLMAINTAINWORKERS'COMpENSAi`IONINSURANCE,ASREOUIREDBYSECTION
,'KC,� 37000F THE LABOR CODE.F�H THE PERFOHMANCE OF TNE WORK fOR WFtICH Tk11S PERM3T IS
ISSVE6.MYw�(,�!CERS'�/p{�PENSAT[iO,,,,(,+INSURANGE CARftiER AND PpLICY NUMBER A/RF CONSTRUCT{ON
y CARRIER ,�+--a-r L_.�•-��'���(��j-�_�T � � S�I�,J� P�.QAN REVIEW -� . 4 .... .__. _,
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d (tHS:,,EctNX�NEHJhoiGEop.tl�LETQ70FTNEPEFUMTFF47RONEFRSJDciEomll.Aas�Yioe)OplEss� PLUMBING --._ ..__,..._.. � -�-j�—�
zi CERTIFf TNAT iN fHE PERFORMANCE OF THE W(5RK FOq WHICH TMI$PERMI7 IS ISSUEU.I MECHANICAL _,�_
(!'S SHOLLNO�EI.IPL4VAN'fPE�$(7NINANYMANNERuDASTOBECOMESUBJEGTTOTFIE
�/j 4MORKE:iS'C4MPEN3ATKN#UWSOfCRLiF�pPNiA,RNDAGREEiHATlFISHOUlDBEtXJME ��SFECTIONFEE
SUBlECT Tq THE W6FHEP5'CC�MPENSATIOfI 7ROVISIONS OF$ECTION 3700 pF'HE LABOR —��
� CO�E,I SMAt1 FO%TYWITH COMPIv WIiH THOSE PROVISIONS 1SSUANCE ��_:� "�U _A._
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� WARNINO:FAIIURE TO SECURE WdRKCR5 CCMiPENSATION COVENpGE is VNLA.wFUL,AND 6HAL4 BE ENERGY PIC _,,,._.,,,,__� �_
� SV&16CTANEMPL4VERTO�:RIMINALPfNALTIESAN�CIVILFMESUPTOONENUNDREDTHOUSANO ENERGYPERMIT
DOlU1A5{St00,Q00},ik AtSDii'IOH FO FHE GOST OF CAMFENSATION,OAMAGfS AS PROVlDED FOR IM — �
� SECTKIN 3708 OF?HE LA@OFl cSpUE,INTEflES'f.AND ATTOFNEY'S FEES. RETENTION FEE' _ _
d CONSTpUCTION LENp�NG AGENCY PRE-ALT FEE:
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4 lNEREBYAFFIRNUNDEAPENAL?YOFPERIVftYTHATTFiEftEiSACAN51'ftUCTlONlEt3OFNGAGENGY .^
FOR THE PERFORMANCE OF 7ME WORK FOR WHICH iM15 PERMIT IS ISSUED(SEC.3097,CIV�C.).
� IENDER'SNAAIE�.�i!,y���_��,.� �L��, _ �..
. F�_ IENDERSADORESS i__
� ICcRT1FYTHATiHAVEFIEAOTHi$APP�ICAFIONANOS7ATETMA;THEA$CJYEMFQAMATbrYiSCOflREC2 TOTAL�EES �� ',., St+
� I AGR6E 10 GOMPLV WITH ALi_CITY AND CAUN'V OflDINANGES ANO STATE UW5 qELATING TO BUILDING
� CONSTRUCtIpN,ANpHEREBYAUTMORI2EREPRESEN7ATNE50FTHISCOUNTYTOENTEflUPONTHE
dHOYE•MENTIQNEO PF�PER`Y FQR INSPEGT1qN PUftPOSES. CQMMENTS
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JOBSITE
ADDRESS OA V i
APN LOT 17--00 TRACT 5Z2.-I6'7
OWNER InC !P
ADDRESS'Ds"
CITY try ZIP'/2f1Z TEL. r C
APPLICANT et//I '!,TEL.Vc
CONTRACTOR_
ADDRESS I&VOI 02 c.
CITY jnr,I c ZIP'1'2 kIL TEL.
ARCH/ENG/
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DESIGNER s
ADDRESS
CITY rti i 8e,ZIP I2.1 TEL.A fl- 3- 1T
OWNER-BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER. IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER V(COMMENCING WITH SECTION 7000)OF DIVISION 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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044. BUSI.
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRACG
TORS UCENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
A-
LICENSE CLASS
LIC. N0. 7 5
DATE CONTRACTOR-rnC
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATON$:
--I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 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
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY KERS' MPENSATIO INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER tU,-e LJ;
POLICY NUMBER
(THIS SECTION NEED NOT BE COYIPLETm OF THE PERMIT I, FOR ONE HLNURED DOLLARS($100)OR LESS
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHPI-L NOT EMPLOY AN/PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE P
OVISIONS.
(,7)_�^'
R
DATE: I-I1"V f APPLICANT: FV+'�� F al
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($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOFI CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV�C.).
LENDER'S NAME, �E///��e j, )
LENDER'S ADDRESS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE DATE
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
PRESS
71Z"FIRMLY
APPLICATION C PERMIT c P/C
I
II
DATE
t'V
NUMBER
#
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
Garage/Carport
W Patio/Deck
LL Pool/Spa
0
Re-Root
Z
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
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MECHANICAL
INSPECTION FEE
ISSUANCE D
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy