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Home My WebLink About15105UI.1)111" I Il.11t �� 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 ADDRESS Y 2 Q e APN LOT TRACT OWNER .S ADDRESS o 'e CITY 4 ZIP% TEL. .3 APPLICANT TEL. CONTRACTO Jq r ADDRESS CITY &A LQ`zwq ZIP 5P17 of TEL, ytd ,Z7R 7 ARCFVENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4 CENSE LAW FOR THE FOLLOWING AEASON (SEC. 7031.5 BUSINESS AND PROFESSIONS ODDS ANYCRYOR COUNTY WHICH REOUMES APERMRTO OONSTRUCT,ALTER IMPROVE. DEMOLISH, OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (CHAPTER P (COMMENCING WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PRO- FESSIONS CODE) ORTHAT HE OR SHE 13 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION-ANY XEMP-TION.ANY VIOLATION OF SECTION 7071.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): D L AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044, SUSI. NESS AND PROFESSK)NS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY W'I10 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, HOWEVENTHE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION, THE OWNERBUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALEL O L AS OWNER OF ME PROPERTY. AM EXCLUSIVELY CONTRACTNO WITH LICENSED CONTRACTORS TO CONSTRICT THE PROJECT (SEC 7044. BUSINESS ANO PROFESSIONS CODE THE CONTRACTORS U. CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND VA 000NTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAO- TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC B.1 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER IL (COMMENCING WITH SECTIO! 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULLFORCE AND EFFECT. LICENSE CUSS UC, NO. DATE CONTRACTOR WORKERS'COMPENSATIONDECLARATION �\- 1 HEREBY AFFIRM UNDER PENALTYOF PERJURY ONE OF THE FOLLOWING DELT-AAATIONS:` I HAVE AND WILL MANTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION SMO OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED. _X.tel HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS RE WIRED BY SECTION 37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' O PENSATION NSUR ANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (DI; SECTION NEMNOT BE CCI.FIETED OFTIE PEFW S FORCNE HUN)AED DOLL, s 6 001ORLES% 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT S ISSUED, 1 SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUr:JECT 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 SHAWL FORTHWITH COMPLY WITH THOSE PROV1510NS. DATE: v[S L3 APPLICANT. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS IF 100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE S A CONSTRUCTION LENDING AGENCY RMA FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC 3097, CIV. CJ. LENDER'S NAME 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 CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. �� 4 y //� PERM ENAME(P SIGNATURE OF PERMITTEE D E PRESS FIRMLY APPLICATION (0 Gv PERMIT ( L. I t P/C DATE v NUMBER / t p ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM C/) GaragofCarpon WPatio/Dock LL PooVSpa 0 Z Re -Roof Commercial - Ib Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J rUrtt LIJ6 LU 0 Z on C U{J v If U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING r MECHANICAL, INSPECTION FEE �� n L ISSUANCE " SMTP ENERGY PIC _ icon ENERGY PERMIQ — — RETENTION FEIjD.2P` PAR PRE -ALT FEE: IVU11-N J 1110'x_ 1'Y TOTAL FEES �0 COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—FInNIoe Copy, PINK—Assessor Copy. GOLDENROD—File Copy, GREEN—Applicant's Copy