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Home My WebLink About17064 (17) -� ,--------. . CITY OF DIAMOND BAR � i �'�`` DEPARTN�ENT OF COIvIIviUNITY&DEVELOPMENT SERVICES — ��_ 21825 E.Copley Drive ESS � � "`%� (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �r� I/� APPLICATION PERMIT /C � o ADDRESS � / ��7(__V 1�� DATE $y'y '�� NUMBER (�� o ISSUE TYPE OCC °T APN LOT TRACT DATE CONST. GROUP p OWNER �L.L�gF�1 ADDRESS L G �� L' �V W ZONING SETBACKS z CITY O IP TEL. FRONT RW ❑_ � APPLICANT e�aRtiiA_��6�GlrG�4� REAR �-� — o SIDE/SIDE STREET RW ❑_ � CONTRACTOR��/a�:�^5'65�/}r SIDE ❑— � ADDRESS;S/D�( Lr �'` ' PROPOSED USE � CITY U�•�D(/l�i�_ ZIP TEL.C�2L7!'�i?-�f?�/ w ARCWENG/ z DESIGNER � EL,�- NO.DWEL. NO. NO. � ADDRESS�t�.,•��,� U� UNITS STORIES BEDROOMS � CITY �[�� ZIP9i�Hr TEL.G`l�Sy3�6 � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION gFR/ADD/REM � 1 NEREBY AFFIRM UNDER PENALTV OF PEFiJURY THAT I AM EXEMPT FROM THE CONTMG70R5 LI� Gef8Q0/CBfPOf1 W CENSELAWFORTHEFOLLOWINGREASON(SEC.)031.58USINESSANDPROiES510N5CODE:ANYCITYOR (n U COUNTVWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAIRANYSTPUC- W P81i0/DBCk Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPL'�CANT FOR SUCH PEFMIT TO FILE A SIGNED w w STATEMENT THAT HE OR SHE IS IICENSED PURSUANT TO THE PFOVISIONS OF THE CONTRACTORS LI� � CENSE LAW(CHAPTER 9(I:OMMENCING WITH SECTION)000)OF DIVISION 3 OF 7HE BUSINESS AN�PRO- rt POOUSPB Q�j OFESSIONSCODE)OftTHATHEOR5HEI5EXEMPTTHEREFROMANDTHE8AS15=0RTHEALLEGEDEXEMP- V TION.ANYVIOLATIONOFSECTION1031.5BVANVAPPLICANTFORAPEflMITSU&lECTS��HEAPPLICANTTO Z RB-R00� � A CIVIL PENALTY OF NOT MIOflE THAN FNE HVNDRED DOLLARS(f500).): O ❑I.ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORIR78fC181 z VJILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OF OFFERED FOR SPLE(SEC.�oa4,BUSI- J � NESS AN�GiiOFE5510N5 CODE THE CONTftACTORS UCENSE LAW DOES NOT APPLV i0 A!J OWNER OF � FPOPERTYNMOBUILDSORIMPROVESTHEHEON.AN�WHODOESSUCHWORKHIMSELFORHERSELFOR m [[ THFIOUGH HIS OR HER OW'N EMPLOYEES,PROVI0E0 THAT Sl1CH IMPROVEMENTS ARE NOT INTENDED OH QOFFEREDFORSRLEIF,HdJJEVERTHEBUIL�INGO�IMPROVEMENTISSOIOWITHINDNEVEAFOFCOMPLE� Z TION,THE OWNER-BLIILDE:P WILL HAVE THE BURDEN OF PROVING THAT HE Oq SHE DIO NOT&IIL�OR � IMFROVE FOR THE PURPOSE OF SALE). w ❑I,ASONMEROFThIEPRO�EflTY,AMEXGLU5IVELVCONTRACTINGWITHLICENSEDCONTRACTORS � TO CANSTflUCT THE PR�JECT�SEG.1o44.BUSINE55 ANO PROFESSIONS CODE:THE CONTPACTORS LI- Valll3�iof1 ' � � ADJ.AREA W CENSEVIWDOESNOTAPPLVTOANONTJEROFAPFOPEflTYWHOBUILD50RIMPROYES?HEREON,AND � WHOCONTRACTSFOflSUCHPROJECTSWITHACONTRACTOR�S�LIGENSE�PURSIJANTTOTHECANTRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE IAWJ. � J O ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS FEASON U � — CC LL' DATE OWNEfl U O -� � I_ICENSED CONTRACTORS DECLARATION W Q . Q I HEf7EBY RFFIRM UN�EF PENALTV OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �r � ,� d 6(COMMENdNG WITM SECTION�000)OF DIVISION J OF THE BUSINE55 AND PROFESSiONS CODE,AND Z w MV LICENSE IS IN FULL FORCE AND EFFECT. m L � LICENSE CL4SS Q'� uc.No. ��1/O 2 � _Z.�` n.� � V pq7E �f'Z K,��__ CONTRACTOR G�G✓E��b�� S a W � WORKERS'GOMPENSATION DECLARATION U �'�,,. � � IHEREBYAFFIRMVNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGOECLARATIONS: � Z Q O IHAVEAN�WILLMAINTHINAGEFTIFlCATEOFGONSENTTOSELF-INSUREFOPWORKERS' 2 Q COMPENSATION.AS PROVIDED BV SECTION 7�OOOF THE LABOR GO�E,FOR THE PER�ORMANCE �U OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � w I HAVEAND WILLMAINTA'N WORKERS'COMPENSATION INSURANCE,AS RE�UIRE�BV SECTION _ � 37000FTHELAB�RCO�E,FORTHEPERFORMANCEOFIHEWORKFOFWHICHTHISPEFMITIS CONSTRUCTION � ` ISSUE�.MY WOPKERS'CAMPENSATION INSURANCE GAHFIER ANO POLIGV NUMBERARE' , l��-'7� j , L,G� � PLAN REVIEW CARRtER_ `^ 7},'�y 0 POLICY NUMBER /�INOG ��/ �^�� ELECTRIG v Z , ¢ (iTi15SECT10NNEFDNOTBEGOMPLE�EDOFhiEPERMfTISFORCNEHUWREDDOLLAF7S(E100)ORLESS). PLUMBING � � u � w MECHANICAL � Z.---� �- Z I CERTIFV THAT IN THE PERFORMANCE OF TNE WOFK FOft WHIGH THIS PEAMIT IS ISSUED,I LJ SHALLNOiFMPLOYANYPERSONINANYMANNERSOASTOBECOMESUdJECTTOTNE INSPECTIONFEE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHATIFISHOULDBECOME 1 SUBJECTTOTHE:WORKERS'COMPENSATIONPRO'JISIONSOFSECTION37000FTHE'J�BOR ISSUANGE �`'� J�-+c`� � COOE,I SHALL FJRTHWITH COMPLV WITH THOSE PROVISIONS. /J/^ }( � DATE�.�L APPLIGANT: �^�'I F�D�f A S��T7 SMIP .'" � 0 w ENERGY P/C ._ -J WARNING�.FAILURE TO SECURE wORNEFS'COMPENSATION COVERAGE IS UNLAWFUL,AN�SHALL BE J SUBJECT AN EMPLOVEP TO CHIMINAI PENALTIES AN[1 CIVIL FINES UP TO ONE HUNDRED THOUSAND � ENERGY PERMIT �OLLARS(f10o.oa0),IN ADDITION TO THE COST OF COMPENSATIDN.�AMAGES AS PROVIDED FOR IN J SECTION3�OBOFTHELABOflCODE,iNTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � \ "� � CONSTRUCTION LENDINGAGENGY PRE-ALT FEE: J O � I HEREBV AFFIRM UNDEN PENALTY OF PERJIIRV THATTHERE IS ACONSTRUCTION LENDING AGENCY __ _ 0- FOR THE PFRFORMANCc OFiHE WORK FOR WHICH THIS PERMIT IS ISSUED($EC.3G9],CN.C.). Z W 2 LENDER'S NAME_ .. --_ _._- � F- IENDER'SADDRE55_ - � ; _ ' ,j� � �� 1 CERTIFV TNAT I HAVE REAO THIS APPL�CATION ANO STATE THAT THE ABOVE WFORMATION IS CORRECT. TOTAL FEES ` � w I AGREE TO COMPLV WI(H ALL GTV AND COUNTV OR�INANCES AND STATE LAWS RELATING TO BUILDING � CONSTRUCTIDN,AN�HEREBVAUTHOR2'eREPRESENTATNE50FTHiSCOUNTVTOENTERUPONTHE 1t{1 �I �J` �„tJ � ABOYE�MENTIONE�PFlI�PERTV FOR INSPECTION GUFPOSES. COMMENTS I•L��1 � - \l`+ � Z /1 —�{ ^� `J � �� /^ -/ " � ��' ..7 S� � �� `"'r��'V--N m PER TTEE NAME(PRINT -�� ',.,�1 vS�zh��o/ N 'ATUREOFPERM EE DNTE ° � = RECPT.NO. PAID BY VALIDATION_- ~ WHITE—Department Gopy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant s Copy � -0 e .�.� �� u� _ � �� '��.d��"i�S a t�j!n � '�'s . . . , . . _ . . __ � _:a-,. ,"�i'�,+,dr �-2S��1 �-----' �/2 b�� ( / � % . _ _ � �-2`6�-01 �------ , _ , ?r _ _ 7 _ ' . . r� . �; � �a�� _ ., .� .m � ., , a��m,��.� . _. . _ _ _ _ _ ; _ _ _ __ ; _ _ ; _ , „ o. � . �,� � � � -- _ �� d �n� � � � � � � � � �� _ �� a��@� �� w �� r��, : _ _ _ _ � �� .�� ya � � � � °� , , � � �� a� ��,�� , _. r , � : � , ��, , ��, , � � � �� _ _ _� < < , � , =�N � �� -� � �� & _ � �� - ,. ,�7 ,ca ,.�a=' '�i.�._.��k....., '� �. .. .... . .... .. ..... . ......, ...... .. .. .. ...... ... . . .. .. . . . ._. ... ..... _.... . .... . .,. ... .. .... ... ... ..... . _..... . .__ . ..... . . . CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE�//�p��r ?�/E•�'w ADDRESS(D�J 7 APN LOT TRACT OWNER�L.L�aErl ADDRESS G !!�G'�V�f/ CITY 0.IP TEL. APPLICANT e..��=aRH/A tCa�S 6�GIs G� � CONTRACTOR�4/�=0 ff.l�/q� �' '�/S tS�J'�/I/� ADDRESS�Q�/ CITY 1/�•�"D(/1�_ZIP TELC�2L�J�iZ�•/ ARCWENG/ . EL�- DESIGNER ADDRESSl�h/'t•�?�v G� CITY GAL, r��ZIP 1/TELL �� SH3ts OWNER-BUILDER DECLARATION 1 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 REOUIRESAPERMIT 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- FESSIONSCODE)ORTHAT HE ORSHE IS EXEMPT THEREFROM AND 7HE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f 500).): ^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES W ITH 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 OW'N 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 ThIE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WNO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOP SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. 8 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 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MV LICENSE IS IN FULL FORCE AND EFFECT. L �� LIC. NQ��SS�o Z LICENSE CL AS S Q �+ / Q ^'� /� DATE� F�f��/CONTRACTOR G' �W�, pp��5t Ic WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TOSELE-INSURE FOR WORKERS' COMPENSATION.AS PROVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 37000E THE IABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WOPKEwRS'COMPENSAT�IfON/INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER_^/�r 0/7/� POLICY NUMBER/INO(b� ��/N (THIS SECTlON NEED NOT BE�MPLETED OF THE PEitMR IS FOR CNE HUNDRED COLIAfiS(E100)OR LESS) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPI OY 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 SECTlON 3700 OF THE LABOR FORTHWITH COMPLY WITH THOSE PROVISIONS. CO DE I S H ALL /J/+ � DATE: �L APPLICANT: G'^L-IF�Dc�f�S�?7 I I 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 ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN I SECTION 3708 OF THE UCBOR CODE,INTEREST,AND ATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.). I LENDER'S NAME LENDER'S ADDRESS I 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 s CONSTRUCTlON,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. � PER TTEE NAME(PRINT �ATURE OF PERM EE DATE 0 0 m 0 0 w z 0 z a 0 0 D W U Z W 0 U Z ��) 2 d X W 0 U W rn Q W Q J 0 Z Q W Z WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy