HomeMy WebLinkAbout16143 � �� CITY 4F DIAMOND BAR `" �
DEPARTMENT OF COMMUNITY 8r DEVELOPMEN'T SERVICES
21b60 E.Coploy Urive Suite 140 �.�'+ �
� `w (409)860-3195 Fax(909)861-3127 � ��.J PRESS
���A�' BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE / � ,r�, g/J,�� ,�* y'
� A€?DRESS LL�'��-"' ��r`�=,�C �!�L'`� DATE CATION --,�.�1 NU B R � ��� �/C
� APtV ldT TRACT �.Z7 �SSUE � TYPE OGC
DATE CONST. GROUP
� OWNEI� v' �
� ADDRESS �'� C? ZONING SETBACKS
�' CITY ��I1'.i d�.� ZIP�.,�L= TEL����7� REORT fiW (-1
� APPLICANT ____ TEL, C�
� SIDEtStDE STREET RW^ ❑
CONTRACTOR SfPE ❑
pG ADDRESS
� CITY ZIP TEI. PR4POSED USE
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DESiGNEii /j 7 �� -- NO.DWEL. NO. NO.
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,� J�t� -7 DESCR�PTION SQ.FL FACTOR PSF ADJ.AREANALUATION
� QWNER-BUILDER DEGLARATION �7�/ SFFt�ADD1REM
�] I HERE9V AFFIRM UNDER PBIALTY OF PERJJRV THAT I AM EXEMPT FROM THE CONTRACTORS U� GdfBQB/G21pOfi
11! qENSEUWfoR7HEFIX.t.4WRrGREASUN{SEc.743f.58U5INES5ANDPt�ESSiONSCODE:AkYCt7YOR {j�
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S77l7EMEN7 THAT HE OR SHE iS IiCEN5E6 PLfRSUtNT t0 THE OFidViSia�7S OF TNE CONTRACTOFiS 47�
� GENS6 UW(CHAG7ER 9(COMMENCINO NATH SECTIDN)400)OF OIVI51ON 3 4K THE BVSMESS AND PRQ� LL' POtlUSPd
FESSpNSCODE}ORTHATHEOHSHE�SEXEMPTTMEAEFSii)MMlOTHEBASISFORTHEKLE�EDEXEMa• (�
TbN,ANY VKSIATKW Oi SECTiON 7031.6 8Y ANV APPL�CANT FOR A PERMfT SUBJECTS 7HE APPt�GANT 70 Z Re•Root
� ACML 7ENILIV OF NO7 MORE THAN FIVE HUNDRED DOLLARS(t5o�.):
� ❑4ASON4IERUFTtiEFF10PEATY,ORIAYEMP�QYEESWtTNWAflESA5THE1flSOLECOMPENSATiON. � �p�pm9tCidl
WILL pD THE wORK,AND TME STRUCTURE IS NOi IN7ENDED OR OFFERE�FOR SALE(SEC.7oM.Bl1Sl- J
�. � NESS AND PROFEffiS�ONS CODE:THE CANTFUCTORS UCENSE I.�W D4E5 NOT APPLY TO AN OWNER OF =
FfloPERTY YrtRJ BUNDS OR IMPi1CWE5 7HEflEON.AND WND OOES SUCN WbRK HIMSEtF QR XERSEIF�R
� C[ iT7R0UGH HIS OR NEHONM EMPLOYEES,7RC7VIDEp THAT SUtli IMPROVEMENis ARE NOT IN7ENpED OR m
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� C I,A5 4VMER O�THE PROPEHTY.AM EXCLUSIYEtY CCNtTflACTlN6 WIiM LICENSED CC1NTftACTORS
TO CCiNSTRUCi TNE PR(JJECT�SEC.�ON,BUSINE$S hNp PflOFE5516N5 CODE:THE CONTflACTOAS LI� VBW6flOf1 _ ADJ.AFEA
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pATE OWNER_ _ �
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� LICENSED CONTRACTOFS DECLARAT�QN -�
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lMfREBYAFFiflMttNDERPENN.TYO+=PEFUUftYT+iA7IAMitCENSE6UPIDERpftOY15iONSK'FCNAFTER u.
� Y(CqdMENQINCi WITH SECTION 70ao)OF DIVISION 8 nF TH[BUSINESS AND PROFE5SIONS CODE,AND Z _�
}{ MY uCENSE IS IN FULL FORCE AND EFFEC7.
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� IHAYE+WDWlLLAWNtAiNACERi4F!qA7E4FfAN5ENT705Et�-�NSUflEFORW9RNERS' S
COMpENSATroN,AS PHqV10Ep BY SECTION 3'1a0 OF THE UBOp CADE,FOR THE PERFORMANCE �U
OF TME WOFiK FaR NMIC:N THI9 PERM(T IS ISSUEp. �
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�HME MID WILL 3AAINTAIN W4RKe'RS'COMPENSAT�N INSURANCE,A&REOVIRED BY SECTION ('�,/fi f �w-.�
4 � 3?Oq OE TMf.ih60fl[XJOE,=0fi TtiE PERFORMANCE OF THE WqRK F4R WtiFC3i Ttti$PEftMl7 15 � f�s ���L.,I'�
� ISSUED.MY WOF RS'fAM'ENSATI4N INSURIINGE CqHRI pND PO4�CY NUMBEflTRE: CONSTHUCTION �"'����rV ��'��
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� vaicvNUM ER � � __....—.. ELECTRIC `
� (iFlk's5E(:lll}1NEH?N079F.CqMiEfF.DOFTFEPE 5F3�F7aNE41U1�DFi�UIX'A.LAR3(SIOo)pFiLESS} PLUMBING `.._..__... �.....— � I�-�.J �"'M
W I CERTIFV THAi M THE PERFORMANCE OF fHE W9NK FOR WHICH THIS PERMIT IS ISSUEp,I MECHANICAL
(�,� SHALL IJOT EMPl.C1Y ANY PERSC?N IN ANY MANNE%50AS TO 9ECOME SUBJECT TO 7HE '
� riORKERS'40MPENSATNJt�1LAW5flFCALIFORNiA+iNOAGREETHATtFFSHOUL�B£COME �NSPECTlO#+IFEE
� SU&.IECT TQ THE WORNERS'CCMIPENSATION PflOVISbNS OF 6ECTI(JN 37D0 OF TNF.IABOR ��'�
CAUE.ISHALLFORTHW{T.�IGOMPLYWITHTN PqOVISI�NS. �SSUANC.E
� .��J�APPLICANT: ����� SMIP .....
� PA7E:. _. .�___ _ ...--
� � ENERGY P!C
J WMNINO:FAILVRE TO SECURE WORKERS'CdMPENSATION COVERAGE IS UNLAWFI.II,AND SHALL BE
� SU9JECT AN EMPL�YER TO CflIMINAL PENALTIES AND CIYIL FINE$tJP TO ONE HUNDPEDTN�VSAN� ENERGY PERMIT
DOl[hfiS(S/0D.000).�N AD�ITpN TQ TNE G057 t}f CX3MPENSATI6N,DAMAGES AS PROViDED FOfl IN - —
� SECTION]7D8�FTNELA90RC47DE.INTERE3T,ANDATTORNEY'SFEES. RETENTIONFEE: _ ,,, „_____
a CQNSTRUC710N LENUING AGENCY PRE-AL7 FEB: ..__�...
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� i HEREBYAFFIRM UNOER PENALTY OF PERJURYTNATTHER IS 0.CONSTCX1t.Ti6N 4ENONG AGENCY
FOP THE PERFORMANCE OF TNE W pK %WHICH THIS RAIIT IS ISS{�ED(SEC. e�,CIV.C.�. +• � '�
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� LENDERS NAMF L'�WN�+^"" / .__�'� /� .... . ,
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� ICERTIFY7NAIIHFVEREADTHISAPP�iCATiOpJAMOSTATETFiATTHEA86YEMFORMAT10Ni5CARRECT. TC�IA�t-E�S t1 �� ,\J `�-,
� I AGREE TO COMPLY WITH ALLCITY ANb COUNTV OHDINANCES AN�STATE LAWS RELATING TO8UILDING }�"V+ . �'
� C'ANSTRUCTION,AND4ERE0YAUTkiORIZEREPRESF.NTATIYE50FTHISCWNTYIDENTERUPONTHE +�1.
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ADDRESS
APN LOT TRACT'27
OWNER rr 7-�
ADDRESS 4A)4 1,113-AI IZAYCOLA-OV-Z
CITY ZIPg TEL.gIyy W? �y
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
DESINER/y
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DESIGNER
ADDRESS A
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CITY-"ZIw cTEL.
OWNER-BUILDER DECLARATION 777
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 REOUIRESA PERMTTTO 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 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(4500).):
^ I.AS 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,BUSI-
NESS MID 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 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).
^ 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 NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
D I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT t 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
f T LIC. N0.
0
DATE CONTRACTOR__
WORKERS'COMPENSATION DECLARATION
I HERE Y AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
HAVE AND WILL MAINTAIN A CERTIF!CATE 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.
jel
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 THI PERMIT IS
ISSUED. MY WOR RS'COMPENSATION INSURANCE CARRI AND POLICY NUMBER RE:
CARRIER A
POLICY NUM ER
(THIS SECTION NEED NOT BE COMA ETED OF THE PE IS FOR ONE V O.NDRED DOLLARS(5100)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
I SHALL FORTHWITH COMPLY WITH THOS PROVISIONS.
CODE,
,I
DATE: __6/L 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 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THEN IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE W RK R WHICH THIS RMI IS ISSUED(SEC. 07,CIV.C.).
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/
/
LENDER'S NAME L
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 OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTIO PURPOSES.
PERMITTEE E(PRINT)
iIGNANSI5 OF PERMITTEE DATE
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
PRESS
FIRMLY
PERMIT P/C
APPLICATION ,0
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DATE N
#
UMBER
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
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REAR ^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL Pool/spa
0
Re-Roof
Z
Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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ISSUANCE S
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ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS -----
RECPT N0. PAID BY- VALIDATION
1
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy