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Home My WebLink About15033�,,.� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 w (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ISSUE TYPE OCC ADDRESS ZONING SETBACKS FRONT RW ❑ REAR ❑ APN LOT TRACT OWNER -2 PAAtt _ ADDRESS _- Tn i rwA A-� CITY ' ` ;-7�� ZIP --� 7s 5 TEL. 5 APPLICANT TEL. CONTRACTOR .ADDRESS �,,_4. CITYRId f1 raj ZIPS�kl-h TEL. l ^ ARCH/ENG/ DESIGNER Q ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF CENSE LAW FOR EFOLLOWING REASON(SEC.7031.5 BUSINESSAND PROFESSIONS CODE ANY CITYOR COUNTY WHICH RE IRESAPERMT(T.-ISTRUCT, ALT ER IMPRO M. SH,OR REPAIRANYSTRUC. ER, TUflE, PRIOR TO ITS ANCE. ALSO REQUIRES THE FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE O SHE IS LICENSED PURSUANT TO PROVISIONS OF THE CONTRACTORS L• CENSELAW(CHA11TER9 MENDING WITH SECTIO )OF DIVISION 30F THE BUSINESS AND PRO. FESSIONS CODE) OR THAT OR SHE IS EXEMPT EFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION. ANY VK ATIDN OF BE 7031-SBYAN PLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIWL PENALTY OF NOT MORE ANFIVE RED DOLLARS(S50D).): ❑LASOWNEROFTHEPR TY,O YEAtPLOYEESWITHWAGESASTHEIRSOLECOIAPENSATION, WILL DO THE WORK, AND THE STR E ISNOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSF NESS AND PROFESSIONS CODE: TRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMP5 REON, AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR THROUGH HIS OR HER OWNE LOVEES, VIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE IF. itTHESUILDI IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- .TION, THE OWNER -BUILD WILL HAVE THE KURD F PROVING�THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PU SE OF SALE). O 1, AS OWNER THE PROPERTY, AM EXCLUSIVELY CO RACTING WITH LICENSED CONTRACTORS TO CONSTRUCT TH PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. -CENSE LAW DOES APPLY TO ANOWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND CTS FOR SUCH PROJECTS I'M ACONTRAI'TOR(S) LICENSED PURSUANT TO THE CCNTRAC� WHO CONTRAEW -TORS LICENSLA.). ❑ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS. DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PEPJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSEW IN FU ORCE AND EFFECT. LICENSE CLASS LIC. NO. _ lf��-s�-=`r p/yy�I DATE , CIO CONTRACTOR &UIKiS <foa- `_-- WORKERS' COMPENSATION DECLARATION - - -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' P COMPENSATION, AS PROVIDED BY SECTION 3700 of THE LABOR CODE, FOR THE PERFORMANCE kiOF THE WORK FOR WHICH THIS PERMIT IS ISSUED. !-V-1 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. MYWORK MIEN INSUR^"•�{[.E CARRIER AND POLICY NUMBER ARE: CARRIER �"( M1 - I � �"I POLICY NUMBER � z * 1 6 - — — L_ M45SECTIONNEED NOTBECOMPLETEDCFTFE PERMIT IS FOR ONE HUNDRED DCl1AA5 (5100)ORLESS) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUFO. I SHALLNOTEMPLOY 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 SE. TION 97000E THE LABOfl CODE,I/§HALL/F}OR�THWTH COMP BE PROVI TIONS DATE. ! _ APPLICANT: I - WARNING:. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECTAN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THATTHERF IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. C). LENDER'S NAME PLAN REVIEW LENDER'SADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHEA13OVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE VE•MENTKNIED POPERTY F�(O�LR�\INSP TION PURPOSES. dL a TTEE NAME (PRI 919MMUMCIPPERMITTEE DATE PRESS FIRMLY APPLICATION PERMIT P/C DATE ICE)NUMBER # D ISSUE TYPE OCC DATE CONST. GROUP a ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ USE 'PROPOSED NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport - W Patio/Deck V- POOVSPa - ZRe -Root Commercial - - m Valuation ADJ.AREA i QUANTITY DESCRIPTION FEE H W Z M J a. Q U_ Z Q S W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL - INSPECTION FEE ISSUANCE s Ir„s-_-' T `a SMTP ' ENERGY P/C i E_.3.: ENERGY PERMIT + i7—,"'.7y RETENTION FEE: PRE- LT TOTAL FEES o - COMMENTS - n RECPT. N0. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor COW GOLDENROD --File Copy, GREEN—Applicant's Copy