HomeMy WebLinkAbout15589 (9) c� CITY OF DIAMOND BAR " �
-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ; ��
,�� 21660 E.Copley Drive Suite 190 i� ,�
� � (909)860-3195 Fax(909)861-3117 �~' PRESS
'� BUII,DING PERMIT APPLICATION Y .� FlRMLY
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l!J CENSELAWWflTHEFOLLCN7NGREASON(SEG7o]1.5B115ME5SANDPROFESSIONSCOOE:ANVCITVOR (n 9 �
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�� 8TATEMENT TFI�T HE OR SNE IS LICENSED WRSUANT TO TNE PROVISIONS OF THE CONTRACTORS LI- �
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FE9SIONSCOOE)OqTNATk1EOR5HE15EXEMPTTMEREFROMANDTHEBA515FOHTHEALLEGEDEXEMP� (�
TION.ANYVIOLATIONOFSECTION7o31.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z pe-Rooi
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^ ❑I.ASOMMEROFTHEPROPERTV,ORMYEMPLOVEESWITHWAGESAS7HEIRSOLECOMPENSATION, Commercial
� YALL DO THE WORK,ANO TiE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.7044.BU51- �
� NE53 ANU PROFESSbNS COOE THE CANTRACTORS LICENSE UW OOES NOT APPLY TO AN OWNER OF
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� LICENSED CONTRAGTORS DECLARATION -,
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(HEREBYAFFIRM UNDER PI:NALTV OF PERJURY THAT I AM LICENSED 11NDER PROVISIONS OF CHAPTER /.''f //
(� Y(CdAYENCINO WITH SEC1'ION 700D�OFDIVISION 90FTHE L'USWESS AND PP.OFESSIONS CODE,AND Z V W�/,C,//
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NIHEREBVAFflRMUNDERPI:NALTVOFPERIURVONEOFTHEFOIWWINGDECLARATIONS�. Z
� _I MAVE ANO WILL M/,INTRIN A CERTIFICATE OF CON5ENT TO SF.LF-INSURE FOR WORKERS' _ /�/�
COMPENSATpN,AS PROVIDED BY SECTION 370o OF THE LABOR CODE.FOR THE PEFFORMANCE U �� ��
OOF TNE WOFK FOR WHICH TMIS FERAIIT IS ISSUED. �
Qw _IMAVEANDWILLM/,IMMNWORKERS'GOMPENSATIONINSUFANCE.ASREOl11qE�BYSECTION
3'/OU OF iFIE LNHOR CODE,FJR THE PEftFORMANCE OF THE WORK FOR WHiCH THIS PERMIT IS �
� ISSUED.MY WORKEpS'COMPENSATION INSURANCE CARRIEP AND POLICY NUMBER ARE: CONSTRUCTION � ' d
> c�rtaien _ PLl�N REVIEW
� POIICY NUAIBER
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� (n�ssEcilorrNE�rarae�FrEooFnfpEw.ui�sFoaoneHut�oneoocuats(siao�or;tess} PLUMBING .. .. ' _ ___
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Z ICERTIFYTHATINTHEPERFORMANCEOFTHEWC0.KFORWHICHTHISPERMITISISSUED.1 MEGHANICAL
C7 SHALL NOT EMPL01'ANV PERSON IN ANV MANNER 50 AS TO BECAME Sl1BJECT TO THE
�/j WORKERS'COMPENSATNNJ LAWS OF CALIFOHNI0.AND AGREE T T IF I SHOUL�BECOME INSPECTION FEE
= SU&1 TTOTHEWORKERS'CAMPENSA710N ROVISIONSO CTION3700OFTHELABOR — . �� �
,ISHALL ONThIWRHCOMPLVWITHT 5 VI^ S. ISSUANCE
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p DATE: ' T_ APPLICAN7: SMIP
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J WARNINa_ AILUflE O SECIJRE WORKEHS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHAILBE ENEFGY P/C __
�y SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHUNDRE�THOUSAND ENERGYPERMIT
OOLLARS(5100,000�.IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION97080FTHELABGFCODE,INTEREST,ANOATTORNEYSFEES. �
Q RETENTION FEE:
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� IHEREBVAFFIRMUNDERPI=NALTVOFPERJURVTHATTHEREISACONSTRUC?IONLENDINGAGENCV ��
FOR THE PERWRMANCE 01=THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.�09I,CIV.C.).
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�ENOER'S NM/E —/ — _�`�. �
F- LENOER'S ADDRE55_ /'� f
� 1 CERTIFY TNAT I HAVE REAU THIS APVLICATION AND STATE THAT 7HE ABOVE INFORMATION IS COFRECT. TOTAL FE ES / � • J J
W 1 AOREE TO COMPIV NATH ALL CI7V AND COUNTV ORDINANCES AND STATE UWS RELATING TO 6UILDING
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CONSTRUCTION,M1D HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE ./�
ABOVE-MENTKKJE�PROPE'3TV FOR INSPECTION PURPOS[5. �-77'� I
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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
APN LOT TRACT
OWNER?ate c + i i P. r-
ADDRESS
L"?E
CITY IDCdoa ZIP'j •
TEL,
APPLICANT TEL.
CONTRACTORAIJ
J = '�
CDDRES
CITY k^Q llk-ZIP TEL. �-_-- 7"I
ARCH/ENG/
4ESiG
ADDRESS--�
CITY y P�TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLCWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA 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 B (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT FIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TON,ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A 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 TiE 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 WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,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 NOTAPPI-Y TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
W OCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTOTHECONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I 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 FOR--E AND EFFECT.
LICENSE LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBYAFFIRM 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 BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
-1 HAVE MID WILLMAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED 8Y SECTION
3700 OF THE LABOR CODE, 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 SECTION NEED NOT BE CLAWI.ETED OF THE PERAgT IS FOR ONE I-JWRED DOLLARS($100)OR LESS
I 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'COMPENSATKKJ LAWS OF CALIFORNIA.AND AGREE T T IF SHOULD BECOME
SUBJ TTO THE WORKERS'COMPENSATION ROVISIONSO ECTlON 3700 OF THE LABOR
I SHALL OR'IHWITH COMPLY WITH T S VI S.
DATE:APPLICANT:
WARNING.ALLURE 0 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 COMPENSATON, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBYAFFIRM 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 THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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.
PfTTE(PR)i
SIGNATURE OF PERMITTEE DATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
PRESS
FIRMLY
APPLICATION I PERMIT P /C,
DATE NUMBER p C7
ISSUE 61
^/n 1 TYPE OCC
D
ATE CONST.G ROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE t�' � 4) Q,1 c
N0. DWEL. N0. N0.
UNITS STORIES BE DROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Garage/Carport
LwLI Patio/Deck
LL- Pool/Spa
0
Re-Root
Z
Commercial
M
Valuation i a ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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F a U//7C rS
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Z oeu "f
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ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C °
ENERGY PERMIT
RETENTION FEE: -
PRE-ALT FEE y
/
10
-,B' L L7
TOTAL F
9, IDIV" 'V 53
EES
FE
COMM ENTS,11"
RECPT N0. PAID BY VALIDATION