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Home My WebLink About16112 CITY OF DIAMOND BAR , --—��`- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� ' C� �� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '°�" BUILDING PERMIT APPLICATION �3� �-�� FIRMLY y JOBSITE APPLICATION �� \{ PERMIT P/C o ADDRESS�C'?� Cr.IL��V�� DATE �� V I NUMBER_. ��_� I� # � APN LOT 4�� TRACT �Z.Z.. �SSUE TYPE OCC 1�I'��_ � � � �` DATE CONST. GROUP _ p OWNER �6;T� C7�t�"•� I�ClL1�. p AODRESS � �(j=�G�� 17N 1�� ZONING SETBACKS W CITY /R�1�1� ZIP��-�+r Z TEL.. � .- 1. (? FRONT pyy-- ❑— � APPLICANT _�/}�'f% TEL. REAR _ �_ � SIDE/SIDE STREEf RW _ ❑_ CONTRACTOR � � , 2 SIDE _ ❑_ ¢ ADDRESS,—� � PROPOSED USE S"Ei'UF/Z. sF�'f'� Q CITY I Vyl�1 ZIP l�i TEL.`��-1`�"7��'4y ¢'�— � ARCH/ENG/ AJ � ADDR SS �"- �� '� �J �S�� NO.DWEL. NO. NO. � "f UNITS STORIES BEDROOMS_ � CITY i13' �a' ZIP Z�i�. TEL�I41-S51i�q tn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I HEREBY AFFIRM UMDER PENALTY OF PERNRY THAT I AM EXEMPT FROM THE CONTRACTOPS LI� Gef29B/CefFlOft l{l CENSEUWFORTHEFOLLOW�NGREASON(SEC.�o315B1151NESSAND7ROFE5510NSCO0E:ANVCITVOR (f� C7 COUNfYNMICHqEIXARESAPERAIRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIPANVSTRUG W Py1i0/DBCK Z NRE,VRIOR TO ITS ISSVMICE.AL50 REW IRES TNE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� �� STATEMENT THAT HE OR SNE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � � CENSE LAW(CHMTER Y Q:UMMENCINO WITH 3ECTION]000)OF DIVISION 3 OF THE BVSINE55 AND PRO� POOUSPO FESSIDNS CODE)OR TMA1 IiE OR SME IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLE�E�EXEMP� � TION.NIYVIp.ATIONOFSECTION7o31.5BYANYAPPLICqNTFORAPERMITSU&lECTSTHEAPPLICANTTO Z Re-Roof � ACML PENALTY OF NOT MOflE THAN FIVE HUNDRED OOLURS(5500)): � ❑I,ASONMEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTMEIRSOLECOMPENSATION, C� CommBfGidl WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70��,B1151� J N NE55 AND PRDFESSIONS CODE�THE CONTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF � CflOPERTV NM1IO BUMDS GH IMPROVES THEfiEON,AND VAIO OOES SUCH WORK HIMSELF OR HERSELF OP � TNNOUGH NIS Oq HEP OWN EAIPLOVEES,PROVIDED TH�T SUCH IMPROVEMENTS ARE NOT INTEN�ED OR m — OFFERED FOR SALE IF,HO WEVEH,iHE BUILDINGOR IMPROVEMEM IS SOL�WITHIN ONE YEAR OF CAMPLE� Z TION,THE OWNER-BUILDE:R WILL HqYE THE BUR�EN OF PROVING 7HA1 HE OR SHE DID NOT BUILD OR � IMPROVE FOfl THE PURPOSE OF SALE). w ❑I,�SOWNEROFhIEPROPERTV,AME%GLUSIVELYCANTRACTINGWITHUCENSEDCONTRACTORS ¢ TO CONSTRVCT THE PROIECT(SEC.701d,BUSIN[SS AND PROFESSIONS CODE:THE CONTRACTORS U� VelUeflGn ADJ.AREA W CENSELAWDOESNO7APPLYTOANOWNEROFAPROPEflTVWFIOBUILDSORIMPROVESTHEREON,AND � WFIOCONTMCTSFORSU:.FI7ROJECTSWIiHACONTMCTOR(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORS UCENSE LAW). J ❑�AM E%EMPT UNDI:R SEC. B.8 P.C.FOR THIS REASON Q 3 � ,y, — cr DATE ._______ _ OWNER__ _ U W � t.ICENSED CONTRACTORS DECLARATION W � I HEREBV AFFIFlM UNDER PENALTY OF PERJUPV TNAT I AM L ICENSE�11NDEfl PROVISIONS OF CHAPTER � d B(COMMENCWAWITHSECTION7000)OFLIIVISION30FTHEOIJSINESSANDGROFeSSIONSCOOE,AND Z X MV LICENSE IS IN NLL FO�iCE AN�EFFECT. m Lll Q' � LICENSE CLASS___� LIC.N0. S � ��`��) � V DATE �`C"EI" IG'� CONTRACTOF �✓`L%T� /� a. W � 1AIORKERS'GOMPENSATION DECLAflATION Q � I HEftEBV AFFIRM UNDER I'ENALTY OF PEPJURV ONE OF TH'c fOLIOWING DECURATIONS: Z � _iHAVEANDWILLAIAINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _ CAMPENSATION,I�.S PROVIDED BY SECTION 370o OF THE LABOR CO�E.FOq THE PEPFOPMANCE U � OF THE WORN FOIa WHICH THIS PENMIT IS ISSUED. � � _I HIIVE AND WILL AIAIMAIN WOqKERS'CAMPENSATION INSURANCE,AS REOl11RE0 BY SECTION Q 3700 OF TME LABC�A CWE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�.MY WORP:FflS'COMPENSATION INSURANCE CARRIEIi M1D POL CY NUMBER ARE� CONSTRUCTION � CARRIEF�L�t-11'�Is--F��'IA—i.t;–��' �AIS ..� PLANREVIEW _ Z Pa�cYNUMBER_ �G QG`1SC'�1 1 �� ELECTRIC Q 0 (iHlSSEGIKNNE9>NOTBEOOIdPLEfmOFTl�f'ERMf'ISFORONEViUrDf1E60CiLARS(SIoO)OqLESSA PLUMBING ��l -__.....__ Z I CERTIFV TNAT Itv THE PERFORMA�CE OF THE WORK FOR WHICH THIS PFRM1715 1S5UE�,l MECHANICAL _ �J SHALL NOT FMNLI]V ANV PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE (/� WORKERS'COMPI:NSATION L4WS OFCALJFORNIA,AND AGREE THAT IF 1 SH(H1LD BECOME INSPECTION FEE � SU&IECTTOTHE'NORKEiiS'(:OMPENSATIONPROVISk7N50FS'cCTlO.`!3]OOOFTHELABOR — � COOE.ISHALLFCqTHWffHCOMPlYW1T OSEPHOVISION3. �+ ISSUANCE p DATE: �_a�r..� APPLICANT: �Jd L=1 L I A'�S C4�1`�l- SMIP • _ -- J WARNINO:FAIWRETO SECVRE WORKERS'COMPENSP.TION CAVERAGE IS UNUWFUL,AND SHALLBE ENEI�GY PIC ._ ___ ' �y SU&IECTANEMPLOVERTOCRIMINAIPENALTIESANOCIVILFMESUPTOONEHUNDREDTHOUSANO ENERGYPERMIT DOLLARS(f100,000�,IN ACDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN � SEGTION3]aBOFTHELAE�OHCODE,INTEftEST.ANDATTORNEY5FEE5. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PpE-ALT FEE: � I NEREBVAFFIAM VNDER�ENAL7V OF PERdURV THATTHERE IS ACONSTPUCTION LEN�ING AGENCV FOR THE GERFORMNJCE�JF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oB],CIV.C.). Z �)�' �1 �,( /�� LENOER'SNAME�� L � �/,-"� �/'� . J 1--' LENDER'S ADDRE55 � ICEpTIFYiHATIHpVEREADTHISAPGLICATIONANOSTATETHATiNEA80VEINFORMATIONISCARRECT. TOTALFEES �7�� •,�J �-' � 1 AGfiEE 70 CAMPIV WIiH ALL CITY AND CWNTY DRDINANCES AND STATE lAWS REUTING TO BUILDING � COFlSTRUCTION,ANDH[i1EBYAUTHORIZEREPRESENTATIVE50FTHISCWNTVTOENiEFUPONTHE AE30VE�MENTIONED PROPERTY FOR INSPECTIqJ PVRPOSES. o COMMENTS J _ — m PEflMITTEE NAME(PRINT� Q _— � � SIGNATURE OF PERMITTEE DATE = RECPT.NO. PAID BV VALIDATION ~ WHITE—�e artment Co YELLOW—Finence Co PINK—Assessor Co GOLDENR00.-File Co GREEN— P PY. VY. 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A��'g`"'e wa.. y ... � " �� .. ... ... .. .. ... ... .. .. ... ... . .. . .. .. .. . 4 > � �� ; �. r'�'��„r� :��' � �R _ � �,,�� 'z�� +,��'�"�gx _ ... . . .. . _ _. . �K. ,-_ �� r� �a, .x'�i'`i . . . __ . _ . . ... .._ .. .. ... . U1,1)IIIJU U�lh . �i 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��^ �C�,IL��yp� �� APN LOT,L� �TRACT S 2.2.. �T_ OWNER�t:T C�"'FQ MI�C,C ILIA. ADDRESS��'� �'I�j 17 N I�� CITY/Ittl)1�1�ZIP�z�r Z TEL. '� �- 7°� APPLICANT_Sf}�'F%TEL. CONTRACTOR�- 2 ADDRESS -�I. CITY I KV�I�1 ZIP � 1-�i TEL.��-Iy"7'y�•'4 y ARCH/ENG/ DESIGNER�IT'f�SGC . CITY��NiI� �i�-ZIP 23�.TEL.�y�7'S�SU�°/ 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 CI7V OR COUNTY WHICH REWIRESA PERMR TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC- TURE,PRIOR TO ITB ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER B (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACML PENALTY OF NOT AAORE THAN FIVE HUNDRED DOLURS(5500).): ^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS N07 INTENDED OR OFFERED FOR SALE(SEC. 701, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS GR gAPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF Ofl THROUGH NIS OR HER ONM EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF,HO WEVER,THE BUILDING OR IMPROVEMEM IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUIIDE:R WILL HAVE THE RURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ 1,AS OWNER OF TFIE PROPERTY,AM E%CLUSIVELY CONTRACTING WRH LICENSED CONTRACTORS TO CONSTRUCTTHE PROTECT(SEC. 7041, 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 SU�..H PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS LICENSE LAW). ^t AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY TNA71 AM LICENSED UNDER PROVISIONS OF CHAPTER B(COMMENCWG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND AIY LICENSE IS IN FULL FORCE AND EFFECT. 1 �� LICENSE CLASS_ LTC. N0. �+ DATE� � C%EJ" �'�CONTRACTOR L'�L%T WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PEPJURV ONE OF THE FOLLOWING DECLARATK)NS: i HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,/(.S PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL AAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE IABC�R CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORA:FRS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: J r ��qf> �� CARRIER��i ��L •�� POLICY NUMBER_W G R� 7 > ��,, (THIS SC-CTX'M NEED NOT BE ODAAPLEfm OF THE PERAYT IS FOR IXJE HIIDRED DOLLAF2S(5100)OR LESS) 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME SU&IECT TO 7HE'+VORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.t SHALL FO R WffH COMPLY WIT OSE P�OVI TH SI ONS. /+ � r L,( �^'�/^'-_�,�/S ) DATE:/_G-y.. �APPLICANT: ��L=] L�f/�I�s-L S C4�S�- 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(5100,000),IN AC DITION TO THE COST OF COMPENSATKN, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LAFIOH CODE,INTEREST.AND ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER�ENALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE 0 F TH ORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 30 E 87,CIV.C. W }) LENDER'S NAME�� L�� -/ � LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE IAWS RELATING TO BUILDING CONSTRUCTlON,AND HEFIEBY AUTHORIZE REPRESENTATIVES OFfHIS CWNN TO EN iER UPON THE ABOVE-MENTIONED PROP ERN FOP INSPECTION PURPOSES. PERMI7TEE NAME(PRINTi SIGNATURE OF PERMITTEE DATE PRESS � �_,� FIRMLY WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy fC-3 i F'�1�� „