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Home My WebLink About16787 (10) � CITY OF DIAMOND BAR i}EPARTMENT t�F COMMIIATITY&DEVELOPMENT SERVICES 2l&2S E.Copley Dr'ive � �,, � (909)$60-3195 Fax(909)861-31ll PRESS � %9� W BUILDiNG PERMIT AFPLICATION FIRMLY �*-� JdBSiTE e f �� / i��— APPLICATION f'1 `'] r-, PERMIT �'n� P/C/� J\� ADDRESS�� ? DATE �� .� NUMBER �l ' # t�� —" �� ISSUE f TYPE _ OC APN LOT TRACT _ DATE t� Q CONSt GROUP p OWNER _�� - � _ � A6DRESS ' ' ' S I�S� �%Z, ZONING SETBACKS z CIN ' "�� 41 r Z3P � f�TEL. FRONT RW �� APPLICANT �r 1+��/,7 '� � � TEL(�3 �Y�"31sf� REAR �_ z SIDEISIDE BTR�ET RW U_.._ � CON7RACTQR` SIDE �_ ADDRESS � CITY Z!P TEL � PROPOSED USE � � � 'C� `� � ARCH/ENG/ . — � DESlGNER — NO.DWEL Nq. NO. � ADDRESS � CITY Z�p 7�� UMlTS STORIES BEdROOMS � � sa DESCRIPTIC}N $Q.FT. FAGTOR PSF AdJ.AREANAIUATION � QWNER-BUILDER DECLARATION � SFR(ADp(REM O i HE(iE6Y AfFiRM UN[>ER PENALTY Or PEfiJ4'RY iHAI'I AM EXEMPT FRpM TNE CONTRACT4RS LI- G8f8Q8/C8(POh � LLl CENSEIAWFORTHEFOLLOWINGREASON�SEC.�031.5BUSINES$ANDPROFESSIONSCODE:ANYCITY00. (� � COUNTYWNICHREQUIRESpPERMtTTOCON57flUCT,ALTER,iMFROVE,0E�10USN.6RREPAikANYSTRVG W Pel'Ip/DeCk �, w TURE,PFIOR TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONEO W .� STqTEMENT THAT ME OR SHE IS LICENSEO R4JRSUANT TO THE PqOV�SIONS OF TNG CONTRACTOftS ti• � .� CENSE tAW(CHAPTER 9 ta�MFNCINf WITH SECTION 700D}OF DIVIS�4N 3�F THE BVS�NE55 AND PRQ� POOIISPB FESSIpNSCODE)ORTHATHEORSHEISEXEMPTTH6REFqOMAN�THEBASISFORTHEALLEGEDEXEMP� (!J � TION.ANYVIOlAM1NOFSECTfON7�3t.56YANYAPP�ICANTFOftAPEftMiTSU6JEG75THEAPPLiGANTTb Z Ra-Roof � ACNt�PENALTV OF NOT MS>RE TNAN FIVF HUN�flED DOLLAqS(F50o).): � ❑I,ASOWNEFOFTNEPROPERTV,qRMYEMPLOVEE5WITHWAGESASTHEIR50lECOMPENSATION, Q �Ofrif718tCi21 Wlil Dp 7HE W4FK,AND THE STRUGtURE!S NOT lNTE�E6 6R QFFERE�F(.7R SALE{SEC.7oa4,BU54 � NESS AN6 PRQfESSIONS p3DE:7 HE GONTRACTOPS LICENSE LAW DDES NOT APPLV TO AN OWNER OF j PROPERTY WHO BUILDS OR IMPROVES THEREtJN.AND WHO DOES Sl1CH WORK HIMSELF OR HERSELF OR tC TNfiOVGNHt9QRt1EROWNEAiPi.OYEES.PROVlDEDTHAT5UCH�tJICROYEMENTSARENdTMTENbEDOR � W IJFFEREDFORSALE.IFHOWEVER,THEBUIL�INGOR!MPROVEMENTISSOL�WITNINONfiVEAROFGOMPIE� � TION,THE OWNER�BUIIDER WILL HAVF 7HE BURDEN OF pFiOV WG THAT HE Ofl SHE DID NOT BUI(.O OR Z IMPROYEFpRTHEPURPOSF_OiSALE}. �� ❑I,ASONMEROFTNEPROPERTV.AMEXCLUSIVELYCqNTRACTINGWITHUCENSEDCONTRACTORS TQ fANSTRUC7 TME PAOJEGT{SEC.70da,BUSINESS AN6 PROFESSIONS GOOE:THE CONTRACTOR$�I� VdIU9ftOI7 ADJ.AREA W CENSELAWpOESNOTAPf'tVTOANOWNERpFAPRUPERTVWMOBUILbSORIMPROVESTHEREON.ANb � WHOC4NTRAGTSFORSUChIPROJEGTSWITNACANI'NACTQR�S)LICENSFDPURSUANTTOTNECONiRAG QUANFITY OESCRtPTIQN ,^ FEE Y TORS tfcE{dSE tAw.}. � ❑I AM EXEMPT UNDEfl SEG. B.8 P.C.FOR THIS 9GASON J �. � U � � j _.—_ ,�. � : � f}ATE '�t_ OWNER�^__ _...... � .. 4 W � UCENSED CQNTRACTORS QECL4ftATiON W <t - CC I HEREBY AFFIFM UNDER PENAL7Y oF PERJUflY THAT I qM LICENSEO UNDER PROVISIONS pF CHAPTFR �, d„ 9(COMMENciNG WlTM SECTIOPI TCOD)OF DtVISiON 30F THE BUSINESSRN6 P{.�FESSIOhS CODE.ANO z w MY LICENSE IS IN FULI FORGE AND EFFECT. m a L�CENSE CLASS ,_ LIC.NO.,,,, _ ,,,,_ � F- J � pATE „_ ^ GON7tiAGT4R,. _—�..._ d W � WpRKERa C6MPENSATI4N DECLAftRStQN � � ¢ � INEREB�AFFIpM UNOEA PENALTVaF PERJURY�NE OFTHE FOLI.OWING DECtARATIONS; Z � _IHAVEANDWIL�MAINTAINACEFlTIFlCATEOFCON9ENTTOSELF•INSUHEFOHWORKERS' _ CAMP[NSATM?N,AS PAOVIDEO BY SEGTION 31600F THE lA�fl C4DE,FOR THE PERFOflMANGE W OFTHE WORK FOq WHIGH TMIS PERMIT IS ISSUED. � d F _,,,__I HAVE AN�WIIL MAINTAIN W6RKEA5'C6MPENSATION IN6URANCE,A$flEOUIRfD BY SECTION ("'�� QQ 3�00 4F THE LABOR CODE.FOR THE PERFORMANCE oF tHE WpRK FOR WHICH TH15 PERMIT 15 - I"'� .ti �t�l J ISSUeD.MY W4RKEAS'GQMPENSATIQN INSURANCE GARRIER AND P{SI.ICY NUMBER ARE: CONSTRUCTION r7 . ��,' ,_.�� } cnAaiEa ___ .. PLAN REVlEW �+,�-v� � POLICVNUMOER i __._.._ �U' ELECTRIC ¢ _ —_�_��—�'� d fMi55EcnoNNEmrx}TeEmb+R.ErEooFn+EaEw:arl5wnavEHurorsEbo�unAs(Eiw�oat,Essy. PLUMB�NG __ w Z t CERTIFY T}iAT IN TNk PERFOPMANGE Of THE WORK FUft WHICtlTHtS PEftMiT IS ISSUED.I MEGHAN�CAL __ (7 SHALL NOT EMPLOY P,NY PERSQN IN ANV MqNNER SO AS 70 BECOME SUBJECT TO TNE � � WORKERS'CQMPENSqTItiN LAWS OF CALIFORNIA,ANDAGREE iHAT IF I SHOULI]BECUME INSPECTION FEE r,�{.,— � 5U8.7ECTTUTHEW4RK£RS'COMPENSAT76NRROVISI�SOFSEC7�CrN3laaOFTHEt_a80R -1�� CODE.I SHALL FORThWITH COMPLY WIfH THOSE PROVISIONS. ISSUANCE d SMIP ..._.. .. � C') p �ATE' APPLICANT: ---- .— . J WARNINO:FAiI.URE TO SECllfiE WORKEFiS'CAMPENSATFON COVERAGE 15 UNLpYJFU�,AND SHAllBE ENERGY PIC __,,,, W SU&IECTANEMPLOVERTOCNIMINALPENALTIESANbCIVILFINESIJPTOONENUNDREDTHOUSAND ENERGYPERMIT OOlLAHS(5100,000),IN ADDIT'.ON TO THE COST DF COMPENSATION.DAMAGES AS PAGVI�ED FOft IN - y�}i J SECTION 3768 QF TNE LABOR CDDE.tNTEREST,AND ATTORNEY'S FEES. RETENTIQN FEE: ^��V y_ � _ — d {�pNSTRUCTION�ENDtNG AGENCY PRE-ALT FEE: a � I HEqEBVAFFIflM UNUER PEN4LTY OF PERJURV THAT THERE IS AC�NSTAUCTION LENPI,YGAGENCY ___ _ _ FqR THE FERWF9AANCE OF THE WORK FOR WNICH TNIS PERMiT IS ISSUEO jSFC.3097,qV Gi. '— � w —' _' _ � IEtJ�EH'SNAME ...__....._� _..... _ — F- I.ENDER'SA�DRESS,._� .._......,_—. �- `�" ....�.._ � Y � ICEFTIFYTHA7IHAVFFEAOTIiISAPPLIGATIONANDS7ATETHATTHEABOVEMFORMA'IONISCORRECT TOTALFEES t� � �k W IAGREETOCOtdP�YWliHACLGTYAN6CQUNTYORDNANCESAN6STA.-ELAWSRE�AT�Nt3TOBVIIDtNG � �' Gl?NSTHUCIIpN,ANpHEREBVAUTHOa12EREPRESENTATIVFSOFfHISCqUNTVTOENfERUPONTHE Z AHOYE-MENTIONED PROPEflTY FqR INSPECTIQN PURPOSES. � CQMMENTS „_ � d ' � ��- �� r e ac4,�� _� � _ _ _—_ m pERMI7T . 1 ¢ -� ..... .� � y'h=k�.�.__ _ Uj IG � FE ITTEE �AiE = RECPT.Rd. PAID 6Y _ VALIDAT�ON_..... � WHITE—Department Copy,YEILOW—Fi�a�ce Copy,PINK—Assessoi Copy.GOLDENROD—Fife Copy,GREEN—ApplicanYs py , �� , ',� ��,; � � "� �� ° ��' � :. = a� �:� , s�ii ��. �.�, . �,w�.;y � .�'i�^�''�*',::. . . � � . �. __._. � �� . . ... ... .. .. ... �1`.��Uf �y.� _�_.... _ ._.. ' '.. . .. . . . .. . . ._. ' . . � . ... . ��„�' . .. .. .. .. � .. . , -� �' A-�::l � ' � � � ' ,, �, }..� ,- � . .... ...- . .. .J ... . . .. .. � ._ ._. .... . . . : _ .. ....... . .- ._ . .. . . . .. .. . , � .,af � . . . ��. � ..... ...... . .. .... ..-: .- »: �� . . . ... . . . .. . . .. . � ; , ., ��,. .. .. � �F�� I i � '. .. . . . . .. . . . . . . . . - � r 6 =• . . . . ,� 9 ��: s,,�t 5�r„m -� . . . 3 � " ._�..��r�i��"��'� �,��°��-� ... . .. . . _. . . ... _ . _. . _ ... ... . � � ;�-� � �a l�r Ps�� ' � . ...... _. ._ ... ._ . _ . � �� ' ��' ar��='�i ' . _.. ....... .. " ': �`R � i.� 9� _ . _ . . . . . .. ..... . .. .. .. . � g �� r��1'�'�#��,�-��p=��'`� . .. . .. _ . .. .. .. . . .. . .... .. �G .. . . . ... . . . . . „ ' -.a� �a =:� � ��. �-. a ,, i -d � t � . . . .. . .. ... ... . . . . .�. , 4�ia�i� i �d �_' ....... ... .._ . . . . .. ... .. : i. � �P�r i�'ti�. ..... . ._ .. . a, , � �r ,��;Wi. . " ,a , �`��;.'', . .. � '. ,�—+ a,;: a 9 ,.. _ .. .... .. . . . . _ _ . �. � i, n..; .v n' , i'� °�.. ��S .. . ._.. _. .... _... . . . . . . ..... _.. _.. U1.1Ji11111 U,1R r JOBSITE i' ADDRESS APN POT TRACT OWNER-(7G��J ADDRESS•"S�S f D IZ CITY��ulh� ;,ir ZIP� �TEL. APPLICANT� •� 1 '�� TEL( �� 3/d� CONTRACTOR_ ADDRESS CITY ZIP 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 LI- CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO 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 THA7 HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TK)N.ANV VIOLATION OFSECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(E500).): ^I,AS OWNER OF THE PROPERN,OR MV 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,HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD W(THIN ONE YEAR OF COMPLE- TK)N,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR 7HE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 704x, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U- CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAWJ. ^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE��OWNER��• LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THA71 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 FORGE AND EFFECT. LICENSE CLASS LIC. N0. DATE CONTRACTOR 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' COMPENSATION,AS PROVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAIIJTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION 3700 OF 7HE LABOR(:ODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (THIS SECTDN NEED NOT BE OOMPLETED OF THE PERMIT IS FOR ONE HUNDRED DCLLARS(E1001 OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY P,NY PERSON IN ANV 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 FORTH WITH COMPLY WITH THOSE PROVISIONS. DATE:APPLICANT: WARNING: FAILURE TO SECUFIE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CNIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(E/00,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND AT70RNEV'S FEES. (:ONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PEN 4LN 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 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 OFfHIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTYI FOR INSPECTION PURPOSES. � .i � �-,�o�e'acE» PERMITT� 1 .... IG RE 177EE DATE CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fast(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY WHITE-Department Copy,YELLOW-Finance Copy, PINK-ASSesso�Copy,GOLDENROD-File Copy,GREEN-Applicant's�bpy