The URL can be used to link to this page

Home My WebLink About17188 CITY OF DIAMOND BAR � ��, � ` r _ �`` / , � �y� DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES / � J �� / � 21825 E.Copley Drive ' ` � (909)860-3195 Fax(909)861-31 l7 ��'�S �%��• BUILDING PERMIT APPLICATION �/, IRMLY o� JOBSITE �'Z� ��',�ES T V I�� ,. APPLICATION ' � RMIT , p/p ADDRESS__ DATE_ 6 3 �� NUMBERI7CFr� � CJ(- y.�3 � ISSUE TYPE OCC APN I.OT TRACT p OWNER L� 2-h j..{��Z.f� - DATE CONST. GROUP p ADDRESS�_�i 'n��''� VttvJ '�' ��—�.��—, —�- ZONING SETBACKS z CITY - vNJ i�2'��Z y ZIP `iI Z4� TE�\'1�}j(;U'�ILb FRONT RW ❑ � APPLICANT L.�Z.A i 1(1(��S TEL. REAR r- ZSIDE/SIDE STREET RW C ¢ CONTRACTOR._ SIDE C, ADDRESS � C��1' ZIP TEL. PROPOSED USE �i��:fi (�ti ,L+�-- 0 o ARCH/ENG/ z DESIGNER a ADDRESS NO.DWEL. NO. NO. � CITY ZIP_ TEL. UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION O SFR/ADD/REM Q I HEREBV AFFIRM UNDER PENALTV OF PERRIRV THAT I AM E%EMPT FPOM THE CONTRACTORS LI- G8f8CJ8/C0fp01� W CENSELAWFORTHEFOLLbWWGREASON�5EC.1031.58U51NESSAN�PROFE5S10NSCODEANYCITYOR (n U COl1NTVWHICHqEQUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE.DEMOLISH,OflREPAIRANYSTRUG Pg�IO/DECI( wTURE,PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNE'J W �C�C�� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROYISIONS OF TME CANTFFCTOflS LI� � CENSE LAW(CMAPTEF9(GOMMENGING WITH SEGTfON loao)OF�IVISION 3 OFTHE BUSINESS AN�PRO- � PooUSpa � FESSIONSCODE)ORTHATHEORSHEISE%EMPTTMEREFROMANDTHEBASISFORTHEALLEGEDE%EMP� (�J I V TION,ANVVIOLFTIONOFSECilON70]1,5BVANVAPPLICANTFORAPERMITSU9JECTSTHEAPPLICANTTO Z Re-Roof �� A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLLARS(5500)J� 0 ❑I,ASONTJEROFTHEPROPERTYORMYEMP�OVFFSWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7oa4,BU51- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW�O[S NOT A7PLY TO AN OWNER OF ? PROPERTV WHO BUIL�S OP IMPROVES THEREON,AND WHO�OES SUCH WORK HIMSELF OR HERSELF OR � THROUGH HIS OR HER OWM EMPLOVEES,PROVIDE�THAT SUCM IMPROVEMENTS ARF.NOT INTENDED OH m QOFFEREOFORSALE.IF,HON'EVEf3THE8UILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,THE OWNEflEU1LDEFi WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTMEPURPOSEOFSAIE). W ❑1,RS OWNER OFTHE PROPERTV,AM E%CLUSNELVCONTRACTING WITH LICENSED CONTRACTORS � TD CANSTRUCT THE PROJfCT(SEC.7046,BUSINESS AND PROFESSIONS COOF�THE CONTRACTORS LI. ValUati0fl - ADJ.AREA W CENSELAWDOESNOTAPF_VTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND � WHOCANTRACTSFORSUCHPROJECiSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTqAC- QUANTITY DESCRIPTION FEE Y TORS UCENSE LAW). Q �IAMEXEMPTUNDERSEC. _B.BP.G.FORTHISREASON Q � -y U � DATE � L 1 OWNER (r(Z.A H�� S � � LU�ENSED CONTRACTORS DECLARATION W Q � I HEREBV AFFIRM IIN�ER PI:NALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHqpTER � d 9(COMMENdNG WITH SECI"ION]oao)OF DIVISIDN 3 OF THE BUSINE55 AND PROFESSIONS CODE,AN� Z `X MV LICENSE IS W FVLL FOR�[AND EFFECT m � IICENSE CLASS_ LIC.NO. � V DATE CONTRACTOR � W � WbRKERS'COMPENSATION DECLAFATION Q � U � I HEREBYAFFIRM UNDER PE:NALTV OF PERJU9Y ONE OFTHE FOLLOWING DECLARATIONS: Z � I HAVE AND WILL MPINTAIN A CERTIFICATE OF CONSENT TO SELF-INSLiRF FOR WORKERS' a Z — _ ¢ CAMPENSATION,AS PROVIDED BV SECTION 3]00 OF THE I.ABOR CODE,FOR THE PERFORMANCE U OF TNE WORK FOR'vVHICH THIS PERMIT IS ISSUED. W � � W I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS qEOUIRED BY SECTION � 310D OF THE LABOR CO�E,FOR THE PERFORIAANCE OF THE WORK FOP WHICH THIS PEFMIT IS '�J C ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBFFARE: CONSTRUCTION J � � CARRIER PLAN REVIEW �P�Z:E� Z POLICYNUMBER_ ELECTRIC Q � (iHI55ECTIONNE�PATBEWMPLEiE00FTFfPERMITISFOqONEHUM1OREDDOLLA{i5(SIoo10RLESS). PLUMBING � �� w ,....:. ... .. . . .. . . . Z I CERTIFVTHAT IN THE PERFORMANCE OF THE WORK FOR WNICH THIS PERMIT IS ISSUED,I MECHANICAL CJ SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SOAS 70 6ECOME SUBJECT TO THE � (J) WORKERS'COMPEASATION LAWS OF CAUFORNIA,AND AGREE THAT IF I SHOUID BECOME INSPECTION FEE �� SUBJECTTO THE WOfiKERS'COMPENSATION PROVISIONS OF SECTION 3laa OFTHE LA60R y��.._� t� �„�� '--,��Y� CODE,1 SHALL FORI'HWITH COMPIY WITH THOSE PROVISIONS. ISSUANCE __�y�_F u � O p DATE: APPLICANT: SMIP �(J W J WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENEF7GY P/C J LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHVNDREDTHOUSAND ENERGYPERMIT DOlURS(ii 00,000),IN ADDITION TO THE GOST OF COMPENSATION,DAMpGES AS PROVI�EO FOR IN J SECTION3�OBOFTHELRBORCODE,INTEREST,ANDATTOftNEY'$FEES. �' w RETENTION FEE: � CONSTRUCTION LENDING AGENCV PRE-ALT FEE: _ � I HEREBVAFFlRM UN�ER PENALTV OF PERJUFiV THATTHERE IS ACONSTFUGTION LEND�NG HGENCY � FOR THE PCRFORMANCE Di THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEG.3091,CIV.G.). Z W � LENDER'SNAME F— LENDER'SFU�RE55 � TOTAL FEES � �Z `��J � �5( �C� � I CERTIFV THAT I HAVE REAG THIS AP!'LICATIIXJ ANp STATE THAT THE ABOVE INFORMATION IS CORRECT. w I AGREE TO COMPLY WITII AI_L CITV ANO COVNTY ORDINANCES AND 5?ATE LAWS REIATING TO BUIL�ING �^ { y d '] ` � CONSTRUCTION,AND HEREBY AUTHORRE REPRESENTATIVES OF THIS COUNTVTO ENTEHUPON THE S�� 'L'�(G.) '�t .YI Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS � _Io' � j� �l' -_ m PERMITTEENFME Q cn 9 � SIGNATUR F PERMITTEE DAT � RECPT.NO. PA�D BY � VALIDATION WH E—Department Copy,VELLOW—Finance Copy,PiNK—Assessor Copy,GOLDENRO�File Gopy,GREEN—ApplicanYs Gopy � � � � '� r' �"�i ��;�� k�,"�� r, i� �� ^`,� � i., 3:i � �"s i��Z�o-� °�� , �� ;�� ° N i �tqir ,„; i m�, .,��w �, ,'r �x��.� . _ „ ' � �.€e��"�4 ewcmw.i�r, ,!�t,n;. . �fiF= '� . . _. ... . , � .�._ , . . . �o��y-o� .�' . _ _ _ v��c „��, ��, _ ��.�� 4 - �... �t ��.� . _ __ _ , d E �R _ ... . ... . . ... ... . .. . .._ .. _.. ._.. i � i s �� i � �a � �H '� b �,��'�� . _ . . _.. .. .... ... _ . ....... � � II .." � ��:'1 "4� �, . _. . . .. . _ .... . . .. � I�q ��, $ : '&'K -,.. � y -; + W �%9( �➢ ': 2�,' .` . .._.. .__.. .... : N .. fi k: � •. ...... ..... ... . . . .. ... . � ��. dr 9. ' . . . _.._ _.. __. .. . °` �'n �$d 'I!� '� � . � r � �—�p .... ..... ... .. ... ... ..... ..... ...... .. i ' ':` .P 3 � . .. .... . .. .... .... . . .. .. . a '; �. � `�. _ �. r �� r � Yn 'd h r�.d. . ��0 "d��"f'�` .. .: ... . . ... .. . °... �,2 h � ' ... .. . ... .. ... .. . . .. ... . ...... ...... .... .. . ��. ,. , e+�;,: .. . .. . . . . .... r _ � Iv r < .: . �., .:.__ . ... . ..... .. ._. . . ..... .... ... .. .. . . 3 � .. .. ..... . ... ... ... . . . .. . . .. .. " p� i : -. .. ... � •'. n � � E_'� z.[ 3 R =:' . . , CITY OF DIAMOND BAR 1 DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION 7oESrVIE I ADDR ESS APN LOT TRACT OWNER Z.t Zh H A 1 7-S ADDRESS'I fJ 7"1:''!Vi-V'J'mot' .. CITY S)rhM-NI ZIP �'ll 74 Y TEL. )DVO i z. APPLICANT LE Z-,&t I A(41 S TEL. CONTRACTOR_ ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. 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 REQUIRES A 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 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 FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^ 1,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 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 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). C I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING 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 ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). I AM EXEMPT U NDER SEC. B.&P.C. FOR THIS REASON DATE L-f OWNER LI Z� H>�R- 1S 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 MY LICENSE IS IN FULL FORE AND EFFECT LICENSE CLASS LIC. N0. DATE CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: -1 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(SI 00)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 ACONSTRUCTION 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. 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 INSPECTION PURPOSES. J dA PERMITTEE NAME SIGNATUR F PERMITTEE DAT WHITE-Department Copy,YELLOW-Finance Copy, PIN DATLICATION NUMRM7 �-y3 DATEb30BER7/#P"'0( ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE^ PROPOSED USE Vi\+t(% 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 Z Re-Roof Commercial CI D Valuation +ADJ.AREA QUANTITY DESCRIPTION FEE cc U W W J CL Q U Z 2 0 W JC CONSTRUCTlON �W PLAN REVIEW I Z; E 3 ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ('+T 0 3(� '] 2001 ISSUANCE Or SMIP U ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES +02. �3'50 C' PC&,q(- COMMENTS � L 1T �5 n RECPT N0. PAID BY VALIDATION