HomeMy WebLinkAbout16246 CITY OF DIAMOND BAR `\�.�'„1
- –1�-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Sui[e 190 pRESS
w (909)86a3195 Fax(909)861-3117
�'������ BUILDIIVG PERMIT APPLICATION � � FIRMLY
o� JOBSITE ��-j� ��,aN �Q.. APPLICATION �.�-�,� NUMBER�� if/C`-� ���
ADDRESS DATE
� ISSUE TYPE pCC
-- APN LOT TRACT DATE CONST. GROUP
°C OWNER
LLO
o ADDRESS ZONING SETBACKS
W CITY ZIP TEL. FRONT RW ❑
� APPLICANT TEL REAR lJ
SIDE/SIDE STREET RW ❑
� CONTRACT SIDE ❑
� ADDRESS PROPOSED USE
� CITY ZIP EL. "
oARCHlENG/ �
� DESIGNER NO.DWEL. NO. NO.
ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TE '
� DESCRIPTION Sd.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER•BUILDER DECLARATION SFR/ADD/REM �9 � �. 'yJ �
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Q I MEREBY AFFlRM UNDER PENALTY OF PENUHV THAT I/JA EXEMPT FROM THE CONTRACTORS ll- G2f2 J8/CBfPOfI � �
liJ CENSEUWFONTHEFOILOYlINGHEASON(SEC.1031.5BVSINESSANDPROFESSIONSCADE�.ANVqTVOR (J� �
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�Z711RE,PRIOR N ITS ISSUANCE,AL50 RE�UIRES TME AVPLICAN7 FOF SUCH PERMIT TO FILE A SIGNED
� STATEMENT 7HAT HE OR SHE IS LICENSEO VURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � pOaUS e
� CENSE L.�W(CHAVTER G(COAiMENCINA WITM SECTION 70a0)OF DIVISION 3 OF THE BUSINESS AND PRO- � P
FE65qNS COOE;ORTNAT HE OR SHE IS E%EMPT THEREFROM AND THE BRSIS FOR THE AILEGED E%EMP-
710N,ANVVqUTIONOFSECT10N7031.6BYANYAPPLICANTFORAPERM7TSU&lECTSTHEAPPLICANTTO Z Re-Roof
� A CML PENN.T/OF NOT MDRE IHAN flVE HUNDflED DOLIARS(1500).�:
^ C�,ASOYAVEflOFTHEPROPERTY,ORMYEMPLOVEESWITHWAGf5A5THEIR50LECOMPENSATION, � CORIR1BfC18I
L WILL DO THE WORK,AND 1}1E STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.�044,BUSI- J
� NESS AND PflOFESSIONS CODE:THE CONTMCTORS LIGENSE UW DOES NOT APPLY TO AN OWNER OF �
VROPERTYV/l'IOBUILDSORNdPROVESTHEREON,MI�WHODOE55UGHWOflKHIMSELFORHERSELFOR m
2 THROUGH HIS DR HEROLVN EMPLOVEES,PROVIDED THAT SUCH IMVROVEMENTSARE NOT IN7ENUED OR
WQ OFFEREDFORSALEIF,HOWEVERiHEBU1LDINGORIMPqOVEMENTI550lDWITHINONEYEAROFCOMPLE-
Z TqN,THE OWNER-BUILDER WILL MAVE TIE 9UHDEN OF PROVING THAT HE OR SHE OID NOT BUIID OR
� IMPipVE FOR THE PURPOSE OF SALE).
❑I,/S OWNER Of THE PROPERTV,AM EXCLVSNEIV CONTRACTING WITH LICENSED CONTRACTORS
� TO LONSTRUCT THE PflQIECT(°-EC.70H.BUSINESS AND PROFESSIONS CODE THG CONTRACTORS ll- VflIU2110f1 ADJ.AREA_
� CENSEUWDOESNOTAPPLYTOANOWNEFOFA7ROPERTYWF!OBUILOSOFIMPROVFSTHEREON,AND
WIqCONTRAC75FORSUCHPRWECTSWIiHACONTMCTOR(5)IICF.NSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE
TORS LICENSE UW.j. �i
OIl1AMEXEMPTUNDEHSEC.__ _ ,. B.BP.C.FOf1THI.SPEA50N � '-'�"� � �
3 — -- �c /� r
u" DATE OWNER_ _ ~ - �
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� LICENSED CONTRACTQRS DECLARATION �y �3'
� I HEREBV AFFIRM UNDEFl PENALTY OF PERIURV TMAT I AM LICENSED UNDEfl PROVISIONS OF CHAPTER � �' /
d D(G�MMENCINOWITMSECTION7000)OFDIVI510N30F(HEBUSINESSANDPROFESSIONSCOOE,AND Z �
X MY LICENSE IS IN FULL FORCE ANO EFFECT. m ��
LLl �
� UCENSE GU 5 _LfQ NO. ' �
V DATE_ _ COtJTRACTOR
� � • • �� �
WORKERS'COMPENSATION UFCLARATION U I S ��'
� I HEREB AFFIRM UNOF.R PENALN Of PERIURV ONE OF THE FO�LOWMG DECURATIONS: Z S �-�
� Q p .
O , � I HAVE AND WILL MAIN7AIN A CER7IFlCATE OF CONSENTTO SELF-INSUHE FOR WORKERS' 2 � / � �
�� COMVENSATION,AS PROVI�ED 81'SEGTION 3"!m OF THE UBOR CADE,FOR THE PERFGRMANf,E W
OF iHE WORN FOF WHICH THIS PERMIT IS ISSUE�. � �� ��J
�
W IHAVEANDWILI.MAINTAINWORKERS'COMPENSATIONINSURANCE.ASREWIREDB'/SECTION ` �j�
Q . 31000F1HELABORCODE,FORTHEPEFFORMRNCEOFTHEWOFKFORWHICHTHISPERMI7IS n I 1 � f �/ �[ 1
ISSUEO.MV KERS'COMPENSATpryMS NCE ARRIERANDPOLICYNVN�BER/A�RE: CONSTRUCTION ' 1\L 1+ �S� �. �I�•`�t.�
jCARRIER C'�� I��e�— PLAN REVIEW __ 7� �\
� ��eEv �� -- ELECTRIC .� "t-'
¢ Cq,�PLE7EpocnkvEw+Ifrtsrc.aoNE4alrDREDDIX.IMs(StoofORLEss} PLUMBING ' ` r ' �
� MECHANICAL -�•���"�_ ��? .��J �
I CERTIFV THAT IN TME PEFfORMANCE OF l"HE NIORK FOR WHICH THIS PEfiMiT IS ISSUED,I --- - -------- +
� SHALLNOTENPIOYANVPERJGNWANYMANNF.R50A5TOBECOMESUBJECTTOiHE INSPECTIONFEE ,_['�
�/j WORKERS'COMPENSA'IpNlpW50FCALIFOHN10.ANDACPEETHATlFISHOULOBEGOME - 1.�
SU&1CCTTOiHEWORKEFS'COMPENSATIONPROVISIONSOFSEGTION9]ooOFTNENBOR � � � � "�..J
� COOF,ISHALLFOfP.'HWIiNCOMPLVWIT�FIdOSEPROVf$IONS.�om�� ISSUANCE
� Y/q,,�I1 T"I�
� DATE: _ APPLICANT: _��JSi. SMIP
J ENEHGY P/C � :
J WARNING:FAILUHETO SECURE WORKERS'COMPENSAfION COVEfiAGE IS UNLAWFUL,AND SHALLBE -'�
— SU&IECTAN EMPLOYER TO CRIMINAL PEYALTIES ANO CIVIL FINES UF TO ONE HUNGRED THOUSAND
LL, ENERGY PERMIT � . f �
OOLURS(fl m,00o),IN AODI710NT0 THE COSTOF COMPENSATION,OAMAGES AS PROVIDED FOP IN -'�-�-- �
J SECTION31080FTHELABORCO�E,INTEREST.ANDATTORNEV'SFEES. RETENTIONFEE: `�,� \����
Q
w CONSTRUCTION LENDING AGENCY PRE-ALT F[E:
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� I HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT THc'RE IS A CONSTFUCTiON LENOING Au[Ncv �
FOF TME PERFOflMPNCE OF THE WO(7K R WHICH THIS PERMIT IS ISSUEU(SEC.3oSl,CIV.G. �
�I1 ��/� 1 'i
� LENDER'SNAMEJ_�S.Sd`G �°PuLT ��,0'..lT.Q2�y? � �- __ __
� LENDERSADDRESS_ — ------- - � •'l
� I CERTIFY iMAT I HAVE READ THIS APPIICATION AND STATE 7HAT TME ABOVE INFORMATION IS CORREGT.
TOTAL FEES �J
W I AGREE i0 COMPIV WITH ALL CITY AND COUNTY ORDINANCESAND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION.AND HEREBY AUTHORIZE REPRESEN7A�IVES OF THIS CWNTV TO ENTER UPON THE
ZABOVE�MENiIONED PROPEflTY FCR INSPECTION PVR�OSES. COMMENTS
� �+�-' �
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i-V� s�,�
(/J '--'__'
� SIGN EOFPFRMITTE! DATE _ _
RECPT.NO. PAID BY VALIDATION
� _
WHITE--0epartment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENR06—File 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
JOBSITE 11
ADDRESS_Mn 0-pay(A)V sm
APN
OWNER
ADDRESS
CITY
LOT TRACT-73 I
ZIP TEL
TEL.
APPLICANT
CONTRACT
ADDRESS
CITY
ARCH/ENG/
DESIGNER
ADDRESS
CITY
OR L Ho
ZIP EL.
D
0
ZIP TE
OWNER-BUILDER DECLARATION
PRESS
FIRMLY
APPLICATION I)PERMIT
/C
NUMBER#
DATE
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWELL N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
Garage/Carport L
W Patio/Deck 00
Pool/Spa
Z Re-Roof
Commercial
Valuation DJ.AREA
QUANTITY DESCRIPTION FEE
U � t
cc
W d - �).
W I�s
1�
wj14
Z
vf /
r7/ J* i
n �
CONSTRUCTION
PLAN REVIEW
°0
ELECTRIC
PLUMBING
�� ��
' 3I?
MECHANICAL•
INSPECTION FEE
ISSUANCE/
SMIP-
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: -.7'J-)y
PRE-ALT FEE:
1
TOTAL FEES
COMMENTS
RECPT N0. PAID BY VALIDATION
11
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 REOUIRESA PERMITTO 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 Y(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).):
D 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 ME.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).
D I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING 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 CONTRAC-
TORS UCENSE LAW.).
D 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.
I HEREBY 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 371YJ 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'COMPENSATION INSU4NCE CARRIER AND POLICY NUMBER ARE.
CARRIER_fP&kFll_I
iiCCnll�s.�-OY LETEDOFTHF: PERMIT IS FOR ONE HUFDRED DIX.LARS($100108 LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSCN IN ANY MANNER SOAS 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 WITII I(OSE PR9V IONS.
DATE: APPLICANT:
iomg
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(51 00,000),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 THE WORK�OR WHICH THIS PERMIT IS ISSUED(SEC. 3057,CIV C
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I 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.
PERMITTE NAME(PRINT)
SIGN E OF PERMITT
DATE
WHITE--Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy. GREEN-Applicant's Copy
3C
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