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Home My WebLink About18677 l�� CITY OF DIAMOND BAR �,�s� ��' DEPARTMENT OF COMMUNITY&DEVELOPIvIENT SERVICES �_, 21825 E.Copley Drive � (909)860-3195 Fax(909)861-3117 �� f �/�� G' PRESS BUILDING PERMIT APPLICATION �� FIRMLY � JOBSITE � �, (/� APPLICATION )I _ �} oADDRESS�-> �I l- ��,Z,�r�/' � � DATE I`�� v�UMB R�� C � `� APN LOT_, TRACT ISSUE TYPE OCC p OWNER �`�+� DATE _CONST. GROUP ADDRESS��" ` � .. , ZONING SETBACKS z CITY .1-�'.-l..l �rn"�i,;7� ZIP' ' � TELc�. _. � :+{�. � FRONT RW ❑ p APPLICANT "- �� ' T��: REAR � ¢ _ SIDE/SIDE STREET Ryy � Q CONTRACTOR_. _ SIOE � ADDRESS � CITY ZIP TEL. PROPOSED USE�"�`l<� .� � ,9 ? .%, ` .�-� w ARCH/ENG/ ,? Z DESIGNER � '� '` � ADDRESS S , w'-y NO.DWEL. � O. ,� NO. � UNITS I STORIES �--- BEDROOMS � � CITY ��' IP �'�:��jEL. . 7 - — � ' � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION pC OWNER-BUILDER�ECLARATION O SFF7/ADD/REM I NEiiEBY AFFIRM UN�ER FENALTV oF PERJURY THAT 1 qM EXEMPT FROM THE CONTRACTORS L6 G8f8J@/CBfpOR �W CENSELAWFORTHEFOLLOWINGREAuON(SEC.]o31.5BU51NE55ANDPflOfES51ON5CODE'.ANVCITYOH (n V CAUNTVWHICHREOUIHESAPERMITTOCONSTRVGT,qLTEH,IM°ftOVE,DEAMJLISH,ORRe'rA1RANYSTqUC Patio/Deck w Tl1RE,PRIOR TO ITS ISSVANCE,AL50 FEO�'IRES 7HE APPLICANT FOF SUCH PERMIT TO FlLE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSE�PUqSUANT TO THE PROVISIONS OF THE CONTRACTORS ll� w O� CENSE LAW(CMAPTER9(COMMENC�NG WI iH iEC-10N 7000j OF DiVI510N 3 OF THE�USINF.SS AND PRO- � POOVSpO FESSIONSCODE�ONTFiA1�HEORSHEISEXEMPTTHEREFROMANDTHE8A51SFORTI�IEALLEGEDFXEMP- � V TION.ANVVIOLATIONOFSf:CTION7031.5BYANYAGVLICAN7FORAPERMITSU&IECTSiMEAPP�IGqNTTO Z Re-Root � ApYiL PENALTV O�NOT MORE THAN FNE HUNDFED DOLLARS(5500;.): p GI,ASOYRJEROFTHFPFOPERTVORMVEMPLOYEESWITHWAGE5A5THEIR50LECOMPENSATION. 0 CofllmefCidl Z WILL 00 THE Y/ORK,AND THE SIRUCTURE IS NOT INTENDED OR OFFERE�FaF S0.LE�SEC.;.�dd.3USI- J � NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOTAPP�Y TO AN OWNER OF j PROPERTV WHO BUILDS OFl IMPlIOVES TMEREON,AND WHO DOES SUCH WORH HIMSFLF OR HERSEIF OR � THROUGH HIS OR HER ONTI EMPLCVEES.PROVI�ED THAT SUCM IM?ROVEMENTSARF NOT INTE4DED OR m QOFFEREDNRSALEIF,HON'EVERTHEBUILOINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,TH[OWNER�9UILOEFI WILL HAVE THE 9URDEN OF PROVING THAT HE OR SHE DID NOT BUIL�OR � IMPROVE FOR'FIE PURPOSE OF SA�E). �yJ OI,ASOWNEROFTHEPROPERTVAME%CLl1SNELVCONTFACTINGWITHUCENSEDCtiNTHACTOqS Q TO CON57RUCT THE PpOJE:CT(SEG�oaa,BUSINESS AND PROFESSIONS co�E:THE WNTRACTOPS LI- Veluetl0n ADJ_AREA W CENSELAWDOESNOTAPPI_VTOANOWNEROFAPROPERiYWHOeUILD50RIMPROVESTHEREON.AND -- � WHOCANTRACTSFORSl1CHPROJECTSWITHACOM1TRACTOq�S�LICENSEDPU175UAN7T07HECONTRAG QUANT�TY DESCRIPTION I Y TORS UCENSE LAW.�. FEE O ❑I AM EXEMPT UNDEFI SEC. __P 8 P C.FOR THIS REASON Q �, s � U � D o H � Z U � UCENSED CO RAC RS DECLARATION � � `� ( ¢ w � CC I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSE�VNDER PROVISIONS OF CHAP7ER � d BICOMMENf.MGWITHSECTON�oW)pF01VISION30FTME8U51NE5SANDPROFES510NSCODE,AND Z w IU1'LICENSE IS IN FULL FORCEAND EFFECT. m � LICENSE CLASS UC.NO._ � V DATE_ CONTRAC70R _ d W � WORKERS'COMPENSATION DECLARATION Q � 1HEREBVAFFIRMUNDERPEIJALTYOFPERJUFYONEOFTHEFOLLOWINf�E0.ARATIONS: � � � Z � __IMRVEANDWILLMAIIJTAINACEPTIFICATEOFCONSENTTOSELFdNSUREFOPVJORCERS' _ 4 CAMPENSATION,ASVROVIDED9vSECilON9]ooO�THELA80RL'OOE.FORTHEPERFORMANCE U � OFTHE WORK FOP N'HICN THIS PERMIT IS ISSUED. � _I HFVE AND WILL MAINTAIN WORNERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTIDN ►�10 Q37000F THE LABOR COOE.FOR THE PERFORMANCE OF THE WORN FOR WHIGHTMIS PEqM1T IS ISSUEO.MY WORKERS'COM7ENSATION INSUftANCE CARRIEft AND POIIGY NUMBERARE' CONSTRUCTION –J � CARRIER PLAN REVIEW `�. �(�('1�L -- �y"� � ¢ FoucvNUMnea_ --.__ ELECTRIC _ Q"�C�5� � (iH155ECilONNEkaNGTBEDJFAR,EfEDOFThEPEidATISFORONEHUND{iEDDCLLARS(yloo)ORLESS). PLUM8ING W Z 1 CEPTIFV THAT IN THF�PEFFORMANCE OF TME WORK F09 WHICN THIS PEftMII l5'�.SSUE�.I MECHANICAL C} SMALL NOT F�dGIOY ANV PERSON IN ANY MANNER SOAS TG BEGUME SUBJECT TO THE � WORKERS'COMPENSATIONLAWSOFCALIFOHNIA,AN�AGHEETHATIFISHOUL�6ECOME INSPECTIONFEE = SUBJECTTO THE WOftKERS'COMPENSATION PRCVISbN$QF SECTION]]JOOF TNF I ABOR � �� CODE,I SHALL FORTHWITH COMVLY WITH THOSE PROVISIDNS. ISSUANCE Q � I p DATE: APPLICANT: _ _ SMIP _ r L W J WARNING�FAILURF TO SECURE WORNERS'COMPENSATION GOVEHAGE IS UNUWFIR,ANC SHALL BE ENERGY P!C J � � SUBJECTANEMPLOVERTOCRIMINALPENALTiESAN�f:,VILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOILARS(f I o0,000),IN ADDITION TO THE COS�OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J 5[CT10N 9]oe OF THE LA80R CODE,INTeRES i,AND ATTORNEV'S FEFS. ,�� OCL RETENTION FEE: )) CONSTRUCTION LENOING AGENCY PREALT FEE: _ � � � I FIEREBV AFFIpM UNOCfl PEN/�LTY OF PERJUFV THAT fHEFE IS A CONSTRUCTION LENDING AI:ENCV � FOR THF�ERFORMANCE OF TIiE WOqK FOR WHI(;H TH1S PERMI'IS ISSUED(SEC.��9].CIV C.). - Z LlJ S IFNDER'SNAME � � _ F– LENOER'ShODRE55 � TOTALFEES � `��.}� � I CERTIFY THAT I NAVE READ T111S APPLICATION AND STATE 1 MAT TNE ABOVE INFORMATION IS CORR[CT � w I AGREE�O COMP�Y WIT4 qLL::ITY AND GOUNTY OHDINANCES AND STATE tAWS aELATING TO BUILDING /d L ✓ d � � CGNSTRUCTION,ANDHEFEBV,4UTHOFIZtREPRcSENTA-1VE50FTNISCOUNTVTOENTERUPONTFE �f 1V Z ABOVE�MENTIONE�GROPEflTY FOF INSPECTION PURPOSES. COMMENTS �� J � — _ m PER EE NMAE(PRINT) � Q � � SIG R I ' 7 — � FIECPT.�p. PAID BY VALIDATION WHITE—Department Copy,YELLOW—Financa CopY.PINK—Assessor Copy,GOLDENPO File Copy,GREEN—ApplicanYs Copy ,.� x L�t�'�-'�j��, "'"i€� " � ��;�� t�a n � � � � _ - _ , �. ��tr� w .�� ' ��ca.v` _ , . r � , a `..; .. ; a :. � �� / , ,� i�yry _ , /�� , ��.o� ,� � _ _ �:�_�� . _ � _ r �._,�:�s �,,�- v�,.- � ,,�.-�e : �, � �. �'� ,� �� w.� � _ � �� .��_ �� /,��-��/� �%,�° � /D,�� / / /�,��o��/�,rS ad,T�irr� � � �,/4 �c�� O�� r��/ ,l� 1�.�7Ya.z �.�� .�� iNs�/� �9 c�- . , r� � � z _ � �/'' �i � i ,s e �� ?. .. . ... �a� � , . .._ . . .. . .. . ... . . .. ... . �n �� $ �i 4 �'�.� 4. n� .. �I. ry-. . �� i 'f,-�.y� a LG`� � � 4�' w. _... . . ... . . ... . _.. . ... ... .._. ...._ i.i; '7'k�'� � _ I a�. ... .. . ..... ._. . .. ..._ . .._ ._ . $ � �� . �2 � ._u . � „ ...... . . N i;x• -• _ ._. .. . _.... o i .,,- =o.� . . . ... . ..... .. .._ ... _ i c = _, i i i _e '9 4 ' _. ... .._.. '. k�.i ��e�,�r ;i . . ... .. .. . _ . `s. �` � .. . . .. . . - . P f a ,. �� iF- • � . .._ _. . .._ ..... ,, .. + .i ' '. . , . . �, . . � . _ _.. .... ._.'. d'�,'r, ' .. . . . a.- ��._ ; �- - .. i'-` ' i Y,� '_'.,- . . .. .... . —� � ..� .. . ...._ ._ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE- ADDRESS T3 I I.,wL"•L TC.>-> � t APN LOT TRACT OWNER ADDRESS VI;I I", CITY TEL.e1SL'1} f APPLICANT r TFL.. r CONTRACTOR ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS S y CITY t;�IPcTEL._ OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE.ANY CITY OR COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT.ALTER,IMPROVE,DEMOLISH.OR REPAIRANY 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 FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^ LAS 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. BUSH 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 W ITHIN 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). ^ 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 NOTAPPI_Y TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON DO LICENSED CO RAC RS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I 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 FORCE AND EFFECT. LICENSE CLASS LIC. NO 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 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'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED 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'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 PROVISIONS. DATE:APPLICANT. 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. 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. 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. A PER EE NAME(PRINT) i4 SIG R T WHITE-Department Copy,YELLOW-Finance Copy, PIN PRESS FIRMLY APPLICATION)L-° I C ,.UMB R(7 DATE"""TTTiiilll ISSUE TYPE OCC DATE CONST GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE^ PROPOSED USE N0. DWEL./.'0. NO UNITS/STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM U) Garage/Carport LU Patio/Deck PooVSpa Z Re-Roof Commercial CO Valuation U,V ADJ.AREA QUANTITY DESCRIPTION FEE L�I Q � H- /Y LU [a J w (D Z CL Z 2 U CONSTRUCTION PLAN REVIEW � (�f• �""lf ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: 1 TOTAL FEES 3 11 4 COMMENTS �p RECPT N0. � � AID BY VALIDATION Iwo9 4t