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Home My WebLink About14915 (19)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES �c 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 851-3117 BUILDING PERMIT APPLICATION JOBSITES, IN APN LOT PACT ADD SS CITY ZIP `/ TEL 4!><t I APPLICANT TEL CONTRACTOR -Q& ADDRESS CITY h ZIP"i)(Vt) TEL ARCFUENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 n AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF CENSE UW THE FCLLOWRO REASON (SEC 7021.1 BUSINESS AND PROFESSIONS CODE ANY CITY OR COUNTY SAPETRMIT TOCONSTi .. ALTER IMPROVE,DEMOUSKORREPAIRANYSTRUC- TURE PRK%i 9 ISSUANCE, A150 REQUIRES 7HE APPLICANT FOR T TO FILE A SIGNED STATEMENT THAT OR SHE IS LICENSED PURSUANT TO THE P S OF THE CONTRACTORS LL CENSE UW 0 (COMMENCING WITH SECTION 7000) of D S OF THE BUSINESS AND PRO- fESb10N9000E)OR T HEORSHEISEXEMPTTHEREFROM THE BASIS FOR THE ALLEGED EXEMP- TION.ANYVXXATIDNO CTION TW .6 BY ANY APPL APER MIT SUBJECTS THE APPLICANT ZD A cNva PENALTY of NOT E THAN FIVE HUNDRED IRS) f O L AS OWNER OF THE ,ORMYEM ES WITH WAG ES AS THEIR SOLE COMPENSATION, WILL DO THE WON(, AND THE IS NTENCED OR OFFERED FOR SALE (SEG 7044. BUS4 NO NESS APROFESSIONS ODDS CTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTYWHOBULDS CRIMP REON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR TWIDUGHMSORHEROYM S. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFT3IED FOR SALE IF, THE OR IMPFOVEMENTIS SOIDWTTNNONEYEAROFCOMPLE- TXxI, THE 01MME 1YLL HAVE BURDEN OF PRDVRNO THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} O LASOWNER OFTHE PROPERTY, AMEX IVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 70N, BUSNION E PROFESSIONS CODE THE CONTRACTORS U- CENSELAWDOESNOT APPLYTOANOWMEROFAPROP WMO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACOWRACTOR( SED PURSUANT TO THE CONTRAC- TORS LICENSE uW )• O 1 Aid EXEMPT LINGER SEG B. L P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I AI'FSW UNDER PENALTY OF PERJUIRY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9( WITH SECTION 7m)OF DMSONS OF THE BUSINESS AND PROFESSIONS CODE. AND I/Y E IS N FULL E AND FFFECL ) E CLASS 'S—/^ c�(l CONTRAcroR WORKERS' COMPENSATION DECLARATION I HEREBYAFFVWI UNDER PENALTY OF PFRNRY ONE OF THE FOUOWWO DECLARATIONS: _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' OOMPENSATION,AS PROVIDED BY SECTION S700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PE!, W R ISSUED. , t I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REQUIRED BY SECTOR 5700 O THE L�B� CODE FOR THE PER RMANCE OF THE WORK FOR WMCH THIS PERMIT IS ISSU ,MY� ATON CARRIER ANA POLICY NUMBER ARE: BIER e POUCYNUMBER V (Ra5 SLOTION NEEANOT BE OOIRIE EDOF7HE F£MRIS FOR DIEHUIIIEDTXXUFIS (SIOMORLM I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKFRS'COMPENSATION LAWS OF CALIFO%AANDAGRE THAT IF ISHOUID BECOME SUBJECT TO THE WORKERS' COMPENSAT/ON PRONSIONS SECTION 5700 OF THE UBO COOEISHIILLFORTMWTH - PROM OATS: �'[�_ APPL CA •'' WARNING: FAILURE TO SECURE WORKERS' NSATON COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINES UP TO ONE HUNDRED THOUSAND DOLLARS I$I0O.MM. N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. NTFREST, AND ATTORNEY'S FEES. CONSTRUCTION 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. 3097, CIV. C). LENDER'S NAME LENDERS ADDRESS 1 CERTIFY THUT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE mT COI./PLY WITH ALL CITY ANA COUNTY ORDINANCES AND STATE LAWS RELATING TO BULDNG OONSTRUCTION, AND RIEREBYAUTHORIZE REPRESENTATNES OF THIS COUNTY TO ENTER UPON THE ABOVEUENTONED P ERTY FOR PECTION PURPOSES. MIREE (Q NATO OF PE EE DATE PRESS FIRMLY DATE APPLICATION–j-' d P/COO—�� NUMBER—// ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDESTREET RW ❑ SIDE ❑ PROPOSED USE+ P I • C- %3• Akac p iM NO. DWEL NO. NO. UNITS STORIES-- BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREWALUATION SFRIADOIREM cn GaragaCalport - LL Patlomw* LL PDOI/Spa Z So -Roof Commercial � T Iii Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q I! - ¢U I U LU LU E7 Z dND r S a DIiN U_ Z Q W CONSTRUCTION 67- CLU // PLAN REVIEW 7 �7/ I 32 - ELECTRIC ELECTRIC PLUMBING MECHANICAL - INSPECTION FEE ISSUANCE SMTP d �y ENERGY P/C ENERGY PERMIT , RETENTION FEE: PRE -ALT FEE TOTAL FEES COMMENTS Gnn) RECPT. NO. PAID BY VALIDATION WHITE --Department Copy. YELLOW --Finance COW PINK—Assessor COpy, GOLDENROD—File Copy, GREEN—Applicants COPY