HomeMy WebLinkAbout17932 (10) CITY OF DIAMOND BAR ^
�--��`'�'—- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _�' ,� �� ; f 1 (�
w 2166C)E.Copley Drive Suite 190 PRESS
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a ADDRESS i i t�2�• �H'����-��-�t� � A`f'C��- �" _ DATE.. �� r� t ,�� UMBER�_��:;���-:�
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APN LOT TRACT DATE CONST. GROUP _
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� OWNER-BUtL4Eft DECLARATION SFR/ADD/REM �
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� i NEREBY AFFlPl.i UNpER FENALTY OF PEKRlRY THAT I AM EXEA{PT FFC?Rd TNE CWiTftAC70R5 lF G8(S�@IC8(�Ott
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� NRE,PNk'Ni Fa ITS ISSUATICE.AL50 REflUTAES TNE APPIiCANT G4F SUCN PER6AIT TO filE A SIGNED (�
STATEMENT THAT NE Oq SHE IS uCENSE�PUR54hN7 TO THE pROVISIONS oF 7NE CONTRACTORS LI•
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FESSqNS ObOE)OR THAT HE OR SHE�S EXEMPT7HEREFHOM ANO THE BASIS FOR TNE At,i.ECED EXEMP�
TION,ANVVKKATqNOF51=CTION7031.5BVANVAPP�ICANTFONAPERMIT5U8JEC78THEAPPLICANTTO Z Ra�Rooi
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WdL p0 TME WOqK,AND'ME STHUC7URE IS NOT INTENbED t7R OFFERED FOR SALE(SEC.7044,BU91� J
NE55 M7D PFlOFESSIONS WOE�.TME CON7'RACT4R5 IiCENSE tAW DOES NOT AFPtY TO AN 04YNER OF
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�qN,TNE OWNEq�BU1LpER WILL HAVE THE BURpEN OF iROVINO THAT H[OR SHE Dlp NOT @UILD 41R
WpqpVE fORT�tE PURPi�SEOF SM.E}.
❑I,A80MMEP OF THE PROPEq'T1;AM EXCIUSNELV WNTRACTING WiTN LICENSED COMMGTORS
� TO CdNSTRUCT TME PROIECT(SEC.704t.BUSINESS ANp PRpFES510N5 CUbE:THE GONTMC70RS LI- VpIUet1011 ADJ.AREA
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� WFIpCONTMCT9FOR8U�iRROJECTSW17HACQNTRACiOHiS)LfCENSEDPUiiSUANTTDiNECPNTMG quANTrrY DESCRIPTION FEE
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� ❑I AM EXEMPT UNpER SEC.� B.6 P C.FOR THIS FEASON � _
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Q '�ICENSECI CONTRACTORS DECLARATION w
� �11EREBY AFFIPM UNDER PENALTV pF PERJURY TNAT 1 AM LICENSED UNDER PROYISIONS OF CHAPTEN � { - i ^ �
4 4{(%�MMENCING WITM SEGTqM 7000)OF DIVISION 3 OF THE BUSINESS AN�PROFESSIONS COUE,AND � l ��� '�-'� -3 �rr' � x ' `' '
X hiV UCENSE iS IN FUtI FORCE AND EFFEGT. � m
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� �NORKERS'COMPENSATION pECLARATION d
� I HERE9Y AFFIRM UNDEFI PENALTV�'JF PEHJURY CN[OF THE fOILOW WG DECURATION5�. �
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� 1 HAYEl�N�WIGI.MAIN7AIN ACERTIFICATEOF CONSENTTO SELF-INSURE FOR WOAKEqS' S
�Cl7MPEN5ATpN,AS PROVIRED BY 5ECl'ION 3]00 OF 7NE LABOR CODE,FORTHF.PERIi7RMANGE C.a
� OF THE WORN FqR 4YMfCH�tlt5 PERkNT 1S ISGUE6. �
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_i H)NEAN6 YYt.i,M+UN7AiN W4RKEft5'CdMPENSATiON INSUflRNGE,AS ftEOUIRED 0V$ECTION
Q37000F THE W30R CYbE,FOHTHE PEqFORMANCE OFTNF WORK FOR WH1CM THtS PEiiMiT iS
� ISSUED.MYV/4RKE�R^-5-'COMPENSATION INSUMNCE CARflIER ANU POLICY NUMEC-f7AFE CONSTRUCTION �_„_._._
¢ � G��"�' L „_. ._.. PtAN REVIEW .....—J...
�, CANRIER_•- . _ ..._ __ _
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w 1 GERTIFY THh7 IN THE QER�'ORMpNCE OF 7HE WbRK FOfl WHICH 7HIS PEPMIT IS ISSUED,I MECHANI�,AL
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C.�} SHALL N4T EMPIOY RNY PERSON Nd ANY MAF7NER SU AS T6 BECOME SU&/ECT T4 THE
� WORKERS'CQIAPENSATION LAWS OF CAL.IGORNIA,MIO AGREE TNA?IF I SF9JUlD BECCIME INSPECTION FEE .i,_,__ ..,,,.—_
SUB.'fCT TO Tk4E WOflKER5'C4MPENSATIOrv AROYtS10NS OF SECTION a700 OG THE LABOR ..Z/'�-� �r?-�Ai
� CAOE.I SNALL FORINWiTN COMPLY WITH TtiOSE pR/pY{SIONS. ISSURNGE . _ __..
� _�� i� '��/��,�� SMIP
p 6A?E. .� APPLICANT : c=_�—. —' .. . ...-.
� EtJERGY P/C � ...._ _-__.
J WARNIN4:FAIUJRE TQ SECURE WONKERS'COMPENSATION COVEMGE IS IJNVIWFVL ANO SNALL BE
LL SUBJECTANEMPIQVERTOCRiMtNALPENALTiESANDCNilFWESUPTOCNEHtlMDFiEDTFi�USRND ENER.{�.�YPERMIT ...
Dl']I.1_ARS(f100,0001.IM ADDITION Tq TME COST 4F CAMPENSATION,DAMAGES AS PROVIDE�FOR IN �-��
� SECTIOt3 3�oa{�TNE tA80R CODE.iNTEREST.ANOAttORNE'f5 fEES. RETENTiON FEE: ,,,.—
d CONSTFIUCTlON LENDING ACENCY pRE•ALT FEE: .... ..— .
CL 1 MERE6Y AFFIflM UNOER PENAITY OF PEFiJURY THAT7NER6 IS A CONSTqUCT10N LENbING AGENCY .
n- FOR TtiE PERWF#.1ANCE OF THE WOHK fOR WH1GH iMfS PEf#MIT 151SSUED(SEC.3oe7,GIV.C.). �� �
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� IENQEH'St.MiE� .— - ..
F- LENDER'SADbRE55 . j /
W1 CEPTIFY THAT I HAVI:REAO THIS APPLIGTION AND uTATE TNAT THE ABQVE INF9RMATION IS CARRECT. 1 C�TA�FE E� '`-'`� � ��-
� tAGftEE T�CpMPlY WITH All G�YAN�CAUNTY ORDINANCESANQ STATE IAWS REUTIN6 TO BUILGING
C%NlSTRUCTIpN.ANp HEREBY AUTHORIZE REPRESENSATtVES OF TNIS COVtJTY TO ENTE(i�PON THE /�/}(�.��/�.{�^��p// yf.. �) f ,}[-�/� j
� PBOVE•MENTNINED P�ROPERTY FpR INSPECTION PURPDSES. COMMENTS ! �I/'/V�C �' U�/r-� 1.���1 W'�r�I���
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SIGNATUREOFPERAIITTEE � DATE �
� RECPT.NO. PAID BY VALIDATION°,;����
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES .. �j I
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
ADDRIESS'.2-c* Rt- L f 1 TRAIL 1 P-
APN LOT TRACT
OWNER I-FA N A pv/
f1tC- lSi-h1TLL
ADDRESS
CITY. Y C! P t!5-"'TEL. 9
APPLICANT I. . L'MW' i '-TEL
CONTRACTOR I�I (; I,t6
ADDRESS ry 1'7
CITY C ZIP 2 TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U-
CENSE LAW FOR THE FOLLCANING 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 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 FORA 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.BUILDEA 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-
CENSE 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.).
^ I AM EXEMPT UNDER SEC. B. E P.C. FOR THIS REASON
DATE OWNER
'LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
- '7�J 7
40 L
C
NO
r/7/
LICENSE CLASS
I
i
DATE I'"'L!."-G a= CONTRACTOR II C
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDEFI 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 3700 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 WORKERS'CCO.MPE,N\SATION INSURANCE CARRIER AND POLICY NUMBER ARE:
E-
1
CARRIER_
4'v
p ! I '1! fC. :XI
POLICY NUMBEN WY.'C
(THIS SECTlON 141--EE)NOT BE OONYLETEDOF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS)
1 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 P VISIONS.
DATE:ti APPLICANT:414
L
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 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 WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
1 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.
111 ioc 1�
PE E Pa1NT)/
2 SIGNATURE OF PERMITTEE DATE
C
APPLICATION PERMIT
DATEI
UMBER)
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Garage/Carport
W Patio/Deck
LL POOI/Spa
0
Z Re-Roof
Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
W
J
W
(D
14-r, 5z'
Z
Z
U
CONSTRUCTION_
PLAN REVIEW
ELECTRIC
/
PLUMBING�. !
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
C--' �
TOTAL FEES
LJJ
/
r
Y
tC
� la
Y
COMMENTS !
rl/r/WZ'
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY OF
INSPECTION HaICOAD
