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Home My WebLink About16235 (9) � ," , ,.. ._ CITY OF DIAMOND BAR � ��;�- � �� ...-- ��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES . 21660 E.Copley Drive Suite 190 (909)86Q3]95 Fax(909)861-3117 PRESS ��'�� BUII.DING PERMTT APPLICATION /' � FIRMLY a DDRIESS L�� / ��-/��II� �SY/T �' DATE CATION 3_'�-�I NUMBER � ��`�/p`C � / ISSUE TYPE OCC � APN LOT TRACT �-Z(s��J _ DATE CONST. GROUP p OWNER o ADDRESS �� ' ��/Zs[Es�(/ j,�" ZONING SETBACKS Z CITY��j�= ZIP -TEL. � FRONT RW ❑_ g APPLICANT��, � TEL' � � � REAR n_ � SIDE/SIDE STREET RW ❑ CONTRACTOR_ SIDE ❑_ Q ADDRESS � , � CITY ZIP TEL. PROPOSED USE r r C ti�, (� w ARCH/ENG/ i, Z DESIGNER ��- S!�/ls � ADDfiESS - O _ / �i.✓ �y✓L� i"Z• NO.DWEL. NO. NO. u� UNITS STORIES BEDROOMS_ � CITY '� tYZ1� -t ZIP��`Q TEL.�_�� OWNER-BUILDEA DECLARATION O��Z DESCRIPTION SQ.FL FACTOR PSF ADJ.AREA/VALUATION ¢ SFR/ADD/REM O O I NEREBY AFFlRM UNI)ER PENALTY OF PERNRY TMAT I M1 EXEMPT FROM THE CANTRACTORS LI- G2l8 Je/CefPOf� W CENSEUWFOHTHEFOILOWINGREASON(SEC.70.3/.5BUSINESSAN�PROFESSIONSCODE:ANYCITVOR (n ZCIX1NiYWHICHREWIRESAPERMRTOCANSTRUC7,ALTER.lA1PROVE.DEMOlISH,ORREPAIRANYSTRUG W Patio/DBCk �l� NRE.PRIOH TO ITS ISSUANCE./iL50 REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FlLE A SIGNED w � STATEMENT TMA1 HE OR SME IS IICENSED GURSUANT TO THE PROVISIONS OF THE C-0NTRACTORS LI- � � CENSE UW(CHAPTER B(COMMENLING WITH SECTION 7000)OF DIVISION 3 OF THE BVSINESS AND PRO- POOUSP2 FESSIONSCODE)ORTHATIIEORSHEISEKEMPTTHEREFHOMAN�THEBASISFORTHEALLEGEOEXEMP� � TION.Mf/VIOLATION OF SECTION 7N1.5 B�ANV APPLICANT FOR A PERMIT SU&lECTS THE APPUCANTTO Z Re-Root F A CML PENALTY OF NOT Mf)PE THAN FNE HUNDRED DOLLARS(f5o0�.): � ❑I,h50NRJEROFTMEPROPERTY.ORMYEMPLOVEESWITMWPGESASTHEIR50LECOMPENSATION, ❑ Commercial WILl00 TME wORK,AND 7HE STRUC7URE IS NO7INTENDED OR OFFERED FOP SALE(SEC.7041,BU51- J N NESS AND PROFESSKKJS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTV NT10 BUttDS OH IMPROYES THEREON.AND NM110 DOES SUCH WORK HIMSELF OR HERSELF OR � THROUGH HIS OR HEH OWM EMPLOYEES.PROVIDED THAT SUCH IMPHOVEIJENTSANE NOT INTENDED OR m OOFFEREDFORS/ILEIF,HOWEVERTMEBWLDINGORIMPROVEMEMISSOLDWITHINONEYEAROFCOMPLE- Z 710N,THE OWNERBUIL�ER WILL HAYE THE BURDEN OF PpOVING THAT HE OR SHE DID NOT BUILD OR � IMPRDVEFORTHL-PURPO&EOFSALE). W ❑I,AS OVMER OF THI:PROPEFiTY,AM EXCLVSIVELY CANTRACTING WITH UCFNSEO CANTftAGTOqS Q TO CONSTRUCT THE PRQII'_GT(SEL.7oM,9USINE55 AND PROFESSIONS GODE:THE GONTRACTORS IJ- V8IU8t1011 _ ___...___. _ AQJ.AREA W CENSEUWDOESNOTAPPLVTOANOWNEPVFAPROVEFiTYWHOBUILDSORIMPROVESTHEREON,AND — � WFIOOJNTRACTSFORSUCHPpOJEGTSWITH�C/JNTfiACTOfl(5)IiCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS UCENSE UW.). � ❑I AM EXEMPT UNDEH SEC. 9.8 P G FOR THIS REASOV J � a 3 � LL _ Q DA7E OWNEP F- Q W �„_, LICENSED CONTRACTORS DECVIRATION w ,� � I HEFlEBY AFFIRM UNDEFl PENILTV OF PEFiIURV THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCWO WITH SEC�IUN 7000�OF DIVISION 7 OF THE BUSINE55 ANG PROFc5510N5 CODE,AND Z �� MV LICENSE IS IN FUI.L fORCE AND EFFEC7. m 0 LICENSE C1A55 � LIC.NO. � ��/ j U DATE ��._ CON7RACTOR � - n. W � - WORKERS'COMPENSATION DECLARATION Q , � 1 HEREBY AFFIRM IJNDFR P-'_NALTV OF PERII,'RY ONE OF THE FOLLOWING�ECLARATIONS: Z � �7 IH�VEANDWILLM:\INTAINAGERTIFICATEOFGQVSENTTOSELF-INSl1REFORWORKERS' _ � Q �COMPENSATION,A;i PROVIDED BV SF.CTION�7000F iHE LABOR CODE,FOR THE PEPFORMANCE U � O �OFTNE WORK FOR WHICHTHIS PERMIT IS ISSUED. � W �HAVE AHD VALL MAINTAIN WORNERS'COMPENSATION INSURANCE,AS REOUIRED BY SeCTION Q 3]OOOF THE LA80F1 COOE,FOR TME PERFORMANCE OF THE WORK FOR WHIGH THIS PEHMIT IS ISSUED.MY KI:HS'CpMPENSATIDN INSUHANC CAFRIE i AND POLICY�NUrMBEft ARF: GONSTRUCTION � CMRIER��/L- �' � r.. C-t�� _—-_._- PLAN REVIEW _ — — Zvaucr nuraeEa__ � � // C7 d. ELcCTRiC Q t� ��—�� a I ir--- � �rwss[cnoraNE�ni[+7eE�EiEooFn¢aE%v��.sroaaaEFn.wDaEODa.�orasisim?oa��ss�. PLUMBING � �`� i1 Z I CERTIFY THRT IN 1 HE PEFPoRMAYGE OF I'HE YKJRN FOH WHICM fH15 PEHMIT IS ISSUED,I MECHANICAL (,'} SFMLLNOT EMPlO'V ANV PEHSON IN ANY MANNF_R SO AS TO BECOME SUBJECTTO THF. � WORKEFS'COMPBVSATIONLAW50FCAUFOftNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE ,_ SUBJECTTOTHE NrORKFRS'(.'OMPENSATION PROVISIONS OF SECTION 37W OF 1HE LABOR T -~j CA�E.ISHALLFOFTHW17HCOMVLVWITHT SEPROVISIONS�.j ISSUANCE ,�-� ,�✓'-/ p DATE:� `��'�,_ APPLICANT: �///c-��- T/UK�TL� SMIP J W0.RNINCa:FAILURE TO SECURE YJOPK'cRS'COMPENSATION COVERAGE IS UNUWFUI,AND SHALLBE ENERGY P/C �y SU9JECTAN EMPLOYER T6 CflIMINAL PENALTIES AND CIVIL FINES UP TOONE Hl1NDRE0 THOUSAND ENERGY PERMIT OOLUFS(f1a0,000).IN ADf�ITION TO THE COST OF COMGENSATION.DAMAGES AS PROVIDEO FOR IN —_. � SECTION 3]OB OFTIE LABOR CODE,INTEREST,AN�ATTOFNEYS FEES. RETENTION FEE: _____ OGONSTRUGTION LENDING AGENCY PREALT FEE � I HEREBV AFFIRM UNDER PENALTV OF PERJURY THAT THERE IS A CONSTRUCTIDN IENDING AGENCY � FOR TME PEHFORMANCE OF THE WORK FOR WH/I�FI TMIS P`ERyM�IT IS IS/$UED(SEC.3097.CN C.�. � LENDER'SNAME��.VNL-' ( ��'• / '��'/ _ _ �'-� LENDER'SADDRE55_ _ W ICERTIFYTHATIHAVEREADTHISAPPIICAiIONANDSTATETHATTHEABOVEINFORMATIONISCARPECL TOTAL FEES (t" ' �J �� IAGREE TO COMPIV WITH i1LL CITV AND CAUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING � CANSTRUCTION,AND HERI=BV AUTHORIZE REPRESENTATNES OF THIS COIINTV TO ENTFR UGON THE Z A80VFAIENTIONEO PPOPE�RTY FOR INSPFCTION PVfiGO5E5. Q COMMENTS � � 7`Yr'"�7 q/i �� v Ir--rw...-.. — m PEqMITTEE NAlAE(P INT) cn _._�,�,p*—��-•-✓ �G�Z G�-`"�L�� /j SIG➢f�1FE OF VERMi DRiE = RECPT.NO. ,'�' PAID BY �i VALI�ATION ~ WHITE—Department Copy,YELLOW--Finence Copy,PWK—Assessor Copy,GOLDENROD—File Copy.GREEN—Applicant's Copy �� ;��.°�°��' �� `��!� �� y- ��:�� '�; � . � � � � � r � � � �� , , � ___ . _ _ _ _ __ _ . — __ _ _ — - � _ . �: � — :_ __ _. .___ _ _ _ __ . � r � ,.. � , t : �� E�,,�. � : . . . . u .� : - �� __ , , . : ..�, ,. , �� , , __ __ ___ �� . :t � � ,<� . . � �� a, _ _ . _�__ _ -- _ , ti��- :�� ,�—�.�� _ _ _ __ —_ _. 3.: , >� ,� _ _ _ _ _ , . _ _ � . . , :; _ _ ..._ , z;,. � � .�e� , . , , . � , .� , a �. 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UI,I�IO�U Ii,IR i 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 � �5��,�� JOBSITE�)3� �� ADDRESS L'J (/�Y/r APN LOT TRACT ZZ(�"'� OWNER ADDRE S �� ,�JL,tlsmt/?,� S 7' � CITY'�� .lam� ZIP-TEL. � APPLICANT�-,�S TEL'� r!' A CONTRACTOR_ ADDRESS CITY ZIP TEL. ARCH/ENG/I DESIGNER 9 .Sl�ils ADDRESS- � /.�c./i2� CITY�Lyt/�%�ZIP/�D TEL. �%� p+-7 OWNER-BUILDER DECLARATION �G�r�^ I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLOWING REASON(SEC. 7037.5 BUSINESS AND PROFESSKNS CODE:ANY CITY OR COUNTY WHICH REWIRESA PERMR TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUG TUBE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SME IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER D (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT 11E OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VKX.ATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT TO A CIWL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).): ^ 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 FOP SALE(SEC. 704x, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BULDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWPI EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS AHE 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. 70x1, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE IAW 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 CONTRAG TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. 9. &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 D(COMMENCDJO WITH SEC TKJN 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS� LIC. N0. � / DATE��. CONTRACTORS- =ik WORKERS'COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERIURY ONE OF THE FOLLOWING DECLARATIONS: HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATKOV,A:i PROVIDED BV SECTION 37000E 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 IABOFI CODE, FOR THE PERW RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY RS' K f COMPENSATION INSURANC CARRIE AND POLICY NUMBER ARE: 1 / %N CARRIER.�?i"� �� L' r � �� ^'/)^'j POLICY NUMBER__�C�� /�!s 19/�C�d (tFDS SECfK)tJ NEED NOT BE COFMLETED OFN iE PEFY� LS FOR ONE HIN-DRED DOLLARS(ft0o}OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLO'V ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE. WORKERS'COMPENSATION LAW5 OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE NK)RKFRS'COMPENSATION PROVISIONS OF SECTION 3700 OF T'HE LABOR CADE.�� WIT Lp��SK�N�r�� ,HW APPLICANT: DATE: � Iif,I� WARNING: FAILURE TO SECURE WORK'cRS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLURS(f 100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 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 CF T RK FOR WHI THIS PER H E W M IT I SI S }LIED(SEC. 3097,CIV.C.). 0 { } /• / v� � LENDER'S NAME��/'�'% LENDER'S ADDRESS I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING CONSTRUCTION,AND HERf:BV AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE TK AB OVE M E N NI E D PROPERTY FOR INSPECTK)N P RPOSES. U / 4{ A � Y j^'�j � J PERMITTEE NAME(P INT) �y��- � SIG RE OFF PE A WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy