HomeMy WebLinkAbout16239 .��i
_�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNI'I'Y&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
{909)860-3195 Faac(909)861-3 t 17 PRESS
����� BUILDING PERMiT APPLICATION FiRMLY
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0 ADDRESS_�f
c� lSSl1E TYPE OCC
APN LOT TRACT ��E7�__ DA7E _CUNST. GROUP
�j OWNER �I f-
o ADDRESS � ! �,p��f�s� ZC}NtNG SETSACKS
w CITY����1'�'�—_— ZIP�Z� TEL.�y�[_�� FRdNT RW_ Cl�
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CONTRACT4R_,__ _ �� C� �
o AdDRESS ------- pq�yppgED USE '
CITY T Z�P ,_T_ TEL. �
w AR�WENG/ T_ —
z DESIGNER � 4'� ��f� NO.DWEL. NO. NO.
� ADdRESS � f UNITS STORlES BEDROOMS_
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s OWNEF•BU�IDER DEGLARAT�ON �^'G/`� SFwA�DlREM
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� I HEHEBY AFFIflM UNQER PENALTV OF PEHAlRv THAT t Mi EXEMPT FROM�t71E CdNTRACTORS ll� Ge�eJe7C81pOlt
W CENSEI,.AWFOR7MEF171.LQWlNGREASON(SEC.7031.58US�NESSNNOPROFESuiON5CADE:ANVqTVOR {(}
� (�OlM/TYWHICMREIXlIHESAPEAMItTOCONSTRi1CT,ALTER.IMPROVE,D&MOLISN,ORREPAIRANYSTftUC- (,U patio/Dack
TUAE,PRM�R TO ITS!$SUANCE,KS6 REOUIRES TME APPIICANT FOR SUCN PERMIT TO FILE ASIGNEO W
57ATEMENT THAi ME OR SME�5 4ICENSED PURStIAM TO THE PROVISIONS OF THE CONTRAGTOR5 U-
� CEt1SE UW(CiUPTER a(CC�MMENCINO WITH SECTpN 7004)OF DIYl510N 3 OF SNE 8U51NESSAND PRO- LL' PooVSpa
FESSIONS�DEjORTMA7H�ORSHEISE%EMPTTHEREFftOMANbTHE9AS19fOfiTHEALl.EGEDEXEMP- (�
T10N.ANYHIDI!Tif1NOFSECTICM17a31.50YANYMPLICANTFtlftAPERMiTSUBJEGTSTHEAPPL�CANT70 Z F{g.R001
� A CML PENALTV OF NOT MpHE TNAN FlYE HUNDPFD DGX.iAAS(3io0)J',
� OI,A60NRVEROFTHEF'FK7PERSY.ORMYEMPCOYEESWITHWRGESASTNEtRSiJLECAMPEN5ATION, C� COmm0�C�91
WILL Od TNE WGRK,ANU THE STflUCTURE iS N6T MTENDED OR OFFERED FOR SALE iSEC.�os�,BUSI� J
NESS ANfI PROFE$SKMiS COOE:7NE(^,QN7RACTORS LIGENSE iAW 06E5 NOT APPI�TO AN OWNER OF
� PflOPERTYYMD8U1L�50RNAPFOY6STH6R[.�N,ANDWHODOESSUCHWORKHIMSEIFOFlHER3ElFQft = . „
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QOFFERE6FORSQEiF.HDVh'✓ER7F�EBUiLDMGORIMPROVEMENT4SSCSLDWITHINONEYE4ROfCOMPLE-
Z TIW,THE OWNEiLBUItDER IVILL HAVE TNE BURDEN OF PFOYWG THAT HE Ofl SHE DID I`XJ�BUtLD OSt
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❑�.AS OWNER OF THE PHbPERiY,pM E%CLUSlVEIY CONTRAGTIN�WITk LICENSED CONTRACTOP3
� TO CANSTRUCT TME PROJECT(SEC.7044,BUSINE5S M1D VNOFESSIONS�DE:THE CON7RpCTOR5 L6 Y81U8l1�f1 ,_„_ �AC7J.AREA
L�f L'ENSELAWDOE9NQTApPIYTOAN4WNER4FAPR0?EATVWH68U1LDSOifiiMPROVESTNEREON,ANO � � �� �� �� –�
Z W/N;700NTMCTSFOflSUCHf'ROJECTSWITHACqNTRACTORig)L�CENSEDPURSUAN7TOTHECONTMG QVANTITY DESGRIPTION FEE
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1'±' DATE __..— OWNER__._..__... ._"_ U
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Qs{ LICENSED CONTRAG70RS DEGLARATI6N �
2 1 HEftEOY AFFIRM UfiOEfl PEkALTY Of?ER1tiRY TNA7 iAM LtCENSED UNDER PROVISIONS OF CMAPT[ft � [`' �G/J L.' t ���
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O �/%�I HAVE AND WILI MAiNTA1N Af.ERTIFlCATE OF CONSEM TO SELFiNSURE FOR WORKeHS S
� CONPENSl1TXXN,ASPH�VlDEDBYS-C.TION3�060FTHElA6GRCODE,FOflTHEPERFORMANCE W ._ ��._��_..__
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W �HAVE ANb WfLL MAINI'AIN WORKEftS'C(7MPENSATIONlNSUftANCE.AS ftEQIiREd BY SECTIbN
4 �'l011 OF RaE LABOH COQ�'c,FGR TNE PERFORMAMCE OF TME WORK FOR WNICH iH�6 PERMIT IS
� 4SSVE�_MY/yy��iKEAS'(7iJMPENSAT#]N�INSUR��ANC/�p ARRIEA AND P CY N(U'TA�9EH/p/p� CONSTI3UGTIQN _ _,_..— _..--
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W 1 CERTlFY THAT IN TNE PERfQRMlrNCE OK THE WORK FOil WMICH THIS P£RM�T IS ISSlJEO,I MECHANICA�
� __._._.. __ ..�
C,7 St4V1 NU7 EMPIOY ANY f'ERSON iN PNi MA#F7EP 90AS i0 BEGOME SUBJECT 70 THE
�j WORK[RS'COMPENSATiON UW59F CA4ii'ORN�A,AND AGflcE TNAT IF I SHOL/LQ BECOME INSPEGTION FEE .,,_._.,._�._.__,_ _-/�--�.-�
� SUCJECT TO THE WORKEfS'CAMPENSATION PROVISIONS OF SECTION 3]OOOF THE UeqN �` �� l
C06E,I SHAL1 FORTMWiTH COMPLY WITH T' SE PAOV1510N5. ISSUANCE ., ._..__ ...._.._.�LJ.�..-..-."�=-
� �.-"��,.-t,1/ ' /��_..- SMIP
�j DATE: _(�._..!._ AF'PLIGAN7 �. ��--.. _..-"..� -
� WAPNINQ:FAKUHETqSECUflEWCiRKEiiS�COMfENSpTIONC4VENAGE15UNL4WNL.ANDSMAL4BE ENEHGYPIC .,,..,,,�_
� SU$JECT RN EN�PIDVER TO CRIfdiNAL GENALTIES AND GIVIL FINES UP TOONE HUNDRED THOU$ANO � �
LL 091.LAR5(5160,006},�N AD1)�'10N 10 THE CAS70F GOMNENSATION,OAMAGES AS PflOVl4ED FQR IM ENERGY PERMIT ___,�,��_,_„,_._�..�._. .._.__
� SECTpN J7o8 OF lHE LPB�R COOE:,INrERE57,PNQ ATTOflNEY'S FFES. RETENTIQN FEE: ..
_..__..-_.�-. ..... _
pW., CONSTRltCT10N LENDING AGENCY PRE-AL7 fEE: ._._ __.
C'C i NEREBY AFFlR61 UNDER PENALTV i�F PERJURV THAT THERE 15 ACONSiRUCTION 1FN01NGAGENCY .__, „ „_.,_ _
d FOR THE PEHFORMANCE OF THE W6RN fOR WIi TH15 PERMIT IS 155 {SEC.909),pV.C.).
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� IENDER'SkAME_�.. . .._.– _ ___ _ _.
H LENDER'SAD�RfSS � .._.. c
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� I CEftTlFYTMAT t HAV�READ TN5 AFPI,�CATqN ANO STpTE THATTHE A60VE MFORMA110N IS CUpRECT. TOTAL FEGS � � �CJ '-'
� iACiREETPCOMVi.VWIiNAtLCITY/�NDGOUNTVORDINANCESANDSTATELAWSRFLATINGTOBUILpMG
� CANSTRtIC�iION,ANDHERE8VAi/TM3RiZEREPRESENTA71VE5qFTHISCOUNTYTOEMERUPOflTHE
M180YE-MEMiONED PAQPFRiY FOR iNSP iow vuAvosEs. COMMENTS
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RECPT.NCJ. __�,_..��__. �.—
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WHITE—Depadment Copy,YELLOW—Finance Copy,PINK—Assassor Copg GOLDENROD—Pile Copy,GREEN—ApplicanYs Copy
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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
FIRMLY
n ?
�/Cs
ADDRESS
o�o�,
APN LOT TRACT
OWNER,! -
ADDRESS 1--
CITY 2/ZI NC Z-TEL 1 �i
APPLICANT TEL.
CONTRACTOR-w
ADDRESS
CITY ZIP TEL.
ARCWENG/
DESIGNER
ADDRESS/
CITYL�llt7�. ZIP TEL9L.�rf1
OWNER-BUILDER DECLARATION(;IZ
I 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 REWIRES A PERMR 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 0(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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500),):
^ 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WALL 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).
^ I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI'
DENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
C1 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
B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE I
D EFFECT
/Y
LICENSE CLASS
L!C
NO
!V/7
DATE- 10"CONTRACTOR/IFf
��� . i
I Y-Q'�-VL'ORK:ERS'COMPENSATION DECLARATION
I AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
IHEREB H
AVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SUCTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
-LLL 1 HAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
i�
37000E THE LABOR CODs,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY I
KERS'0
UMPENSATION INSURANC ARRIER AND PO ICY NU
MBERRf�
L
UM
OU
CARRIER�'"��
POLICY NUMBER
,/M4 EEDNNOISE COMPLETED OF THE PEEWATTtS FOR ONE E RIFAJREODD,LARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY 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 WORKEFS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
THWITH COMPLY WITH T SE PROVISIONS.
C
DE. I SHALL F
0
OR
DATE:.y(,_APPLICANT fir
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 3700 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WrTHI
S PERMIT IS IS ISO(SEC. 3057,CIV.C.).
S
LENDER'S NAME_�/�/L%"
LENDER'S ADDRESS
1 CERTIFY THAT I 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
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIOND PRO
ERTY FOR NS ON PURPOSES.
P
PERMITTEE N
(PRI
SIGNATU F ERMITTEE DATE
IFOFO
-APPLICATION PERMIT P/C
DATE 7 NUMBER p
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW D
REAR D
SIDE/SIDE STREET RW D
SIDE 0
PROPOSED USE L C�C
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM
Garage/Carport
W Patio/Deck
LL
Pool/Spa
)
Q�
Re-Roof
Z
0 Commercial
5
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
U
W
Z
a
Z
Q
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL_
INSPECTION FEE
ISSUANCE c� �-
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