HomeMy WebLinkAbout16236 CITY OF DIAMONb BAR �r'
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21664 E.Coplay Drive Suite 194
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Q I MEREBV AFFIRM UNDEp 7ENAl.TV OF PERJURV THAT I AM EXEMPT FROM THE CONTMGTOpS ll� [igfdJB/C8f(70l2
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Z 7URE,PRIOH TO ITS ISSUANCE,AL90 RE4UIqES THE APPLICANT FqR SUCH PE%MIT TO FlLE A SIGNED w Pa��f�C�( � ';` �
S STA7£LiENT hiAT HE OR SHE�5 LICENSE6 Pt1RSUAtlT Tq THE PROViSiQ(i$OF TNE C(}NTR0.CTOR5 ti- � }
CEfiBF UW(diAPTEH B(GOMMENCINO WITH SECT�ON 7000)OF DIVISION 3 OF THE 9USINESS AND Pq0- POOUSPfi
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� ❑1,�SOM'NEROF7tlEPRQPERTY,ORMYEMPLOYEESW4TNWAGESASTHfIflSOIECOMFENSATWN, �OtnrffelCiB)
MM�p0 TNE WORK,At1D THE STNUCTt7RE 15 N07 iNTENDED 4R OFFEREO fOR SALE�SEC.7W4,BUSI� �
� NESS AND PHOFESSbNB OOpE:7H6 CANTMCTtlRS LICENSE LAW pqe5 NpT APPLV TO AN OWNER OF � L'I ^�[ ' � � �
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� iNFSX1GM HfSOR NER OWN EMPLOYEES,PflOVIpEO THAT SUCk11MPROVEMENTS ARE NpT INTENDED QR m
UA OFFEREOFORSFLEIF,NOWEVER7NEBUILpINGONIMPPOVEMENTISSOLDWITHINqNEVEAROFCOAAp�,E- U Y �- �
ZTIOM,THE QWNEft�Bt1tLAEli W4i1 t4lVE 77i£euRl7EN OF Pfl�ViNG TNXT NE 6A SHE Di6 NU7 BUItD OR �`
= IMPp6VE FOR TryE PUPi'OSE OF;;AI.E�. �
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W CENSELAWDOESNOTAPPLY70ANONTIEROFApFOPERTVWF�108UILDSORIMPflpYESTMEREON,AND �" � "— - i
� WHUCQN?RACTSFOR5UCHPFlOJECTSWRHAC4NTMGTOft{St�{CENSEDPURSUAMTTOFttEC%fNTflAG (}IJANTITY 6ESCRIPTI4N, FEE
� � TORS LICENSE UW}.
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LL !l1EREBY�FFIRM IJN�EH AEN%TV�Of PEfL'URY TtUT i AMlICENSED UNOEfl PftOViStGNS Oi CNAPTER p/�{
{i Y(iXSiA6iENCOKi WITH SECTiON]OOp)6F�IYISION 30F 7HE BUSINES$IW D PROFFSSIONS CODE,AND Z ` /?`'4 1�
uA1Y IICENSE IS IN FULI F4RCE AN�EFfECT. � „/� ��� —"
� LICENSE C SS � LIC.NO.� � ������ r
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� WORK£RS'COMPENSATIGN DECiARATION ' Q �,.�.s,p
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� I HEflF JJ'FIflM Vt1DEft PENALN CtF PERIURY ONE OFTME FOIIQWiNG OECiA�iAT�PIS' Z ��/r j �' �
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� IMAVEANOWILLMA�N7AINACERTIFICATEQFCONSENTTOSELF�INSUREFORWOAKERS' _ �y
COMPENSATION,AS PROVI6F0 8Y SECTIC]N 3�5d 4F TNE lAeC1R CObE,FON THE PEFFORMANCE CJ ��3�Y �
� Of TME WOPK FtlR WHICH rHIS VEHMIT IS ISSUEO. � f t -^�
� IH�VEAND WIl4MAINTAIN WpfiNERS'COMVENSATION INSt1RANCE,A5 REOUIRED 8V SECTqN ['�
� 370POF THE LA6Qft COOE,FOfl TkE PERF4PMANCE�F THE W4RK fpR W WCH TH13 PEfltAiTlS � jJ� `� �
� ISSUEO.MY p£R' ENSATKJN IMSUflA�N^CyE CAR I iCY NUM H AR: CONST{�UCTION ���{'+'�j� �����./
j caaR�aR J'��� � ..' PtAN REVIEW �� � ....
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� tCERTIFY74iATiNTHEi�ERFtrRMhNCEOFTHEJ✓(7RKFORWHICHTHISVEflMITI5155UED.l MECHANICAL fj�-�,� _.�._�.��"� �
SHFLL NOT EEAPLOV ANV�EpSON IN qNV MANNER 50 AS TO BEGOME SUBJECT TO THE
rJ} WORXERS'COMR£NSA±fONLAW50FCRtiFpRH�A,ANOAfiNEE7HA7IFISHpUlO$[COME � GNSFECTIONFEE „_, �
SUBJECTTOTHEVXJRNERS'COMPENSATIONPqOVI510NSOF$ECTION37040FTHELABQR ��� ��
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p OATE�L L,,,."��,4._. APPLICANT� �{, NC../[•�� SMIP �4��, — �"'�lA •�___�.
� ENERCoY PJC _.. '��`7-t��� ` �
WARN{NG:i"AILUAE 70 SECURE WORKGRS'COMPENSATION GJVERAGE IS UNLAWFUL,AND SHALL BE
�y SU&IECTANEMPLtlVERfOCRIMINALPENALTIESMlOCIVIIFINESUPTOONENUNDPEDTNOUSAN� "l l, �.. fiC�
ODti.ARS{;too,a0},IN AbDfTiON TO TNE GtrST QF C�APENSATR,N7,DAA{A6ESA5 PROVIQED FDR IN ENERGY PERMI7 __,_,,,, _ ,J� - ^� �/"
wSECiION 3ipe OF THE IABoft COOE,INTEREST,ANpATTORNEY'S FEES. RETENTION FEE: _ �-_]�� �*��}
(� CpNSTRUCTION LEN4�NC�AGENCY PRE-ALT FEE:
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¢ !HEREBY AFFlRM UNCER�ENA4TY OF PEfUVRY TNATTHEFIE IS A G6NS7Rl7CTIOM IENOMG AGENC,Y � '�
GORTNE PERWRM.WCE Of TNE WORN FO (W�H�IGIiTH15 PEFMIf IS ISSUED(3EC.3qB7.CIV.C.).
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,0. I AGREE TO COMPLV WITH ALL CI7Y ANb COUNTY ORDINANGES AFID S?ATE LAWS PELATING TO BUILDING J
,� CONSTRUC71tlN,AND HEREBY AU7HORIZE REPRESENTATIVES OF THIS CDUN'fV TO ENTER UPON TNE
� RBOYE;-MENTK}NEDFROPEATYFORINSPECTlON PURPOSE5.
1+� COMMENTS_^
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ADDRIESS c 37a 5 Cf7W0 V IsT R C)
APN LO T CT
OWNER
ADD SS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACT
ADDRESS
CITY ZIP 2TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SECJ531.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQIIIRESA 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 9(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).):
^I,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 NUT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I,AS OWNER OF TINE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW).
^ 1 AM EXEMPT UNDER SEC. S.A 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.
LICENSE C SS LIC. N0.
DATE-CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HERE AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 37300F 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 WHICI4 THIS PERMIT IS
ISSUED. MY R ENSATION INSURANCE CAR I P CY NUM R AR
CARRIER
li7J�II
P�ENCED LETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($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 WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVI IONS.
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DATE L L 1LL_APPLICANT: ET H61 4 Ci/
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 LABOR CODE. INTEREST,AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE
PERFORMANCE OF WORK FO VYHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.)
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LENDER'S
ADDRESS
LENDERS
I 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.
PERM? E NAWIi(PRINT)
SIG OF PERM(DATE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
PRESS
FIRMLY
APPLI PERMIT DATE CATION -._NUMBER Ito/J� p/C 0
J1
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRO NT RW ^
REAR ^
SIDE/SIDE STREET RW
L
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1
SIDE
�
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. F TOR PSF ADJ.AREANALUATI N
SFR/ADD/REM AO 'I(1 0 C L W
U) Garage/Carport
W PatieFBrac�C . L' !•
, T
LL Pool/Spa
Z Re-Roof
Commercial
D 13A /3 4U
U
Valuation ',I L' W1 Ot J ADJ.AREA
QUANTITY DESCRIPTION FEE
J
s �
a
W I .
W /
EL 1-4 Af P-;'-)
Q
U
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CONSTRUCTION 1�75
PLAN REVIEW
ELECTRIC
PLUMBING 1 L
MECHANICAL
INSPECTION FEE
ISSUANCE u
SMIP L'j�t�•\-C-
ENERGY P/C
ENERGY PERMIT •� ''i
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
BUILDING PERMIT APPLICATION