HomeMy WebLinkAbout16891 �r� _ CITY C}F LtIAMC7ND BA8 �
DEPARTMENT QF COMMUNITY&bEVELOPMENT RV CBS ��
216b0 E.Copley Drive Suite 190 "�' `�,
(904j&60-3195 Fex(909)861-3117 �^� � ��� ✓ � � PR ESS
� '"%A*^�� BUILDING PERMTT APPLICATION FIRMLY
� JOBSITE ` APPLICATION ��"� � PERMIT -� P/��- � v7K�
o ADDRESS�1� 1C��,�1�'t�i Y� pATE G NUMBER #
� -y ISSUE ^TYPE pCC
� AAN lOT TRACT {Q.L—� DATE CONST.„^ GROUP
¢ OWtJER
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ADDRESS � ' � ZONING SETBACK5
� �RQNT RW ❑�
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� ADDRESS pRpPpSED USE
o CITY _ IP TEL.
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� DESIGNER--���1� f ` � NO.DWEL. NO. NO.
`�_' ADDFiESS UNIT5 STORIES BEDii40MS
� CITY ZIP 7EL ?
� DESCRIPTION SQ.FT. FACTQR PSF AqJ.AREANALUATION
�
� OWNER-BUILDER DECSARATION SFR/AU6IREM ,'S`;1 t: � �z „ `-� � �� .� �
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p I MEREBY AFFlFOA UNDEfl PENAITY OF PE%JURV THAT I AM EXEMPT FROM THE CQNTflACTURS LI- � G8f8J8JG81jWR �O' � X ^' �� C � -.�� �
ti! CENSELAW(-0HSHEFiXU]YItP1�REA50N(SEG.7N1.58USINESSANDPf�FES5ION5CbQE:ANYCtNOR
C.� COUNfYWMCHREIXIIRESAPERMfTTOCONSTHl1G7,/�t.7ER.IMPROVE,DEUOLISH,4RREpAIRANYSTRUC- W Pa�io/Deck �
�� TUflE,PRIQR TO ITS kSSUANCE..U.SR1 REOUIRE5 THE APPUCANT FOR SUCH PEHMIT T4 FlLE A SIGNED �
STATEMENT THAT HE UP SHE 15 IICENSED WPSUANT TO iHE PRqViSlONS 6F 7FiE CONTRACTOR8 li-
� CENSE UW(CHI.PTER 9(COMMENGNO WITH SECTpN Yooa)OF DIVIGION 3 OF THE BUSWESSANO Pft0- �'�' PooUSpa
FESSqNS CODEj OR THAT ME OR S+1E IS E%EMPi TFlEREfRSJM AND FHE 8A515 FOR TME ALLEGED EXEMR-
V TION.ANVVIOUTIONOFSECT!ONlq31.58VANYAPPLiGANTF4fiAPERMi75UeJECTSMEAPPLIChNTTO T� {.�e-A00�
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� ❑1,ABOWNEROFTNEPAOPEHTT.OFitAYEMFL6YEESWiTHWAGESAS'�HEIRSOIECOMPENSATiON. Cl COmmBrcial
MnLL DO 7HE WORK,ANO THE STRUC7URE IS NC1T INTENDEO OR OFFEREb FOR SALF(SEC.7aa.BUSI- J
� NESS MIO VROFESSIONS CqDE:THE CANTMCTOflS LICENSE lAW OOES NOT a�PPLY Td AN 9WNEp OF � !t � '._ � �j ���' !� }'�.
PqOP£RTY H'tK7�tRDS OR MiPROVES 7HEREON,AND WM6 CX5E5 SUC�I VN7RK HIMSEIF tSR NERSEIF OR
� THRpUf3NHISORHEROWNEMVLOYEES,PROVIDEDTHATSUCHIA1PqOVEMENiSARENOTMiENDEPOR m ����1 ,,� /J� r) 'E '��-\ ��: I."(,� i��
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� IMpROVE FOF THE PURPOSE 6F SALE�. .s' `-a•,� r '
� ❑I,ASONMEROFTHEPflOPERtY,F3AEXQUSWElYCOkTftAGf1NGWii}ILiCENSEDCpNTflkCTbRS
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z wHocan'raactsFonsucr+ar�crsx.r++Acc7r�Tcwc»aRts)uc[*�s�aau�u,wrroTMEcorrra,ao- ('�I�nNTiTY DESCRIPTtON FEE
F- 7oH5 UGENSE LAW.).
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O ❑i AM EXEMPT UNDER SEC. ___ 8.&P.C.FQR ZHI$REASON � u � . �� ' ��f
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u- o�re owr�Ea —— .__� v r � -
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0 LiCENSED CQNTRACTOflS OEGI.ARATION W � [, L i�
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i FiEREBY AFFERM UNOER PEN,IITY OF PERJURY TNAT t AtA�tCENSE6 tN7DER PROYISK�NS oF CriaP7Ea � r i.- ��
d Y(fX)AIMENCM'tl WITM SECTN:7N 7000)OF OIVISION 3 OF THF 8{�SwES5 ANti pROFES5lON5 CODE,ANP � ���
X MY IICENSE 4S{N FULL FOFlCEAMO EFFECT. 1'�'_ — �. �r�
ll� (� � � �- ' 1
� tICENSE GLASS__ . LIC.N0.. � �"��. —� J
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DATE
� ��(�' WORKERS'CCIMPENSATiOIV UECLARATION ,[ �„ :Y� ,`y� , (� �
� " a '
� I HEREB'�AFFSNM�1ND£R PENAL7Y OF PERJURV ONEOF THE iOLLOWiNG PECU�SATqNu'. -i,`r t � ��
d � ��
d tHAVFAMDWil4MAMM7AikACERT�iCA?cGFC�N5EMT705ECF-iNSUREFOflK�RKER$' S ��'�}
� �COMVENSATION.AS PROVIDE�BV SECTION alno OF ihlE LABOR CODE.fpR THE^ER WRMANCE f.7
�OF 7HE WOfiK F"OFl WMICN THIS PERMIT iS ISSUEG- W y � ' !� f�'
� �
W , , —......
�1 HAVEAND WILLMAIN7AIN WORKERS'CGIMPEN9ATION INSURANCE.,AS REpViflED BY.^rECT16N � �,=�,%
QY yTno aF TFIE IAPOA CODE.FOR THE PfRWRMANGE Of Tt�W4RK fJft WttiCH TkiS PEAMIT IS — +
_ 155UE�.MY ERS'COMPEMSA7JON INSU E GARHIE�ANG POUCY NUMBF}tAR<F: , � CONSTRUC'f�ON ��'� .._.
J . "���,.T+_—. PLAN REVIEW . LC� .?S l..
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� I CEATIFY THAT IN THE PERFORMPNCE OF iNf WOfiK FOR WHICH THIS PEPMIT lu ISSUED.I MECHANICAL _,,,, � �J�.} �,)„L`'� �},.!�_ �/�,
Z �
(� S41A:LN0T FMpIOY ANY�ERSON W RNY MANNER SO AS TO 6ECOME SU6JECTtO THE J
N tYORKEflS'CQMFENSAT6�N lAWS OF GALSF6RNtA,ANO AGflEE THAT iF i SN6U�0 BECOME INSPECTICSN FEE �
S SUBJEC'fTOTHEVIORKERS'(bMPENSATIONpNOVISION50FSECT10N39000FTFIELABOR �$�.^SUANCE „ � ,'��'�"vJ � � �'
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SiERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE ��
ADDRESS%CYe� le(I r 1 V f!
APN LOT TRACT S(�7
OWNER
ADDRESS$)
CITY ZIP C i)TEL. L_x-,I J1
APPLICANT SCA-j-t'TEL. 'NOL
CONTRACTOR
ADDRESS
CITY IP'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 REOUIRESA 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
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ 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 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).
D 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
0 I AM EXEMPT UNDER SEC. B&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM 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 FOFICE AND EFFECT.
LICENSE CLASS LIC. N0.
„tom
DA
E
CONTRACTOR .%.)
T
�p
Ex e WORKERS'COMPENSATION DECLARATION
I HEREB�4 AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
yi
+'�][�7! I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
6/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
E AND POLICY NUMSERAARE
ISSUED. MY ERS'COMPENSATION INSU F CAARRII
I
CARRIER-I
POLIO-Y NUMBER
'I,S_0-
(THIS SECTION I.D
N07 BE OOh9'
ET
D
F TH
L
E
0
E 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 T ASE PPR
OI
S1
ONS
},
Y
7
DATE: 1 APPLICANT._.PJ/�
/
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(WNCCH THIS 1TPERMIT
IIS ISSUED(SEC. 3097,CIV.C.).
{
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i
IV
I
t
LENDER'S NAME
$
V
•Vrne 51
LENDERS 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.
PERMITTEE NAME(PRIN4
IM {I j'� 0
SIGN R OF PERMITT DATE
WHITE-Department Copy. YELLOW-Finance Copy, PIN
PRESS
FIRMLY
APPLICATION J .Z 0
PERMIT
DATE-J L•� NUMBER 11� #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE
N0. DWEL. NO . N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM St J 1
U) Garage/Carport 1 (a
W Patio/Deck I
LL
PooVSpa
0
Re-Roof
Commercial
-� (c> ) '�t 1,
L' #
Val uation DDJI
A REA
QUANTITY DESCRIPTION FEE
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W .w%
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PLAN REVIEW _
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE I�V. �.�V
SMIP L I'),
ENERGY P/C A
ENERGY PERMIT �(I a
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES �L)
1
COMMENTS
RECPT- N0. PAID BY VALIDATION
CITY OF DIAMOND BAR
INSPECTION RECORD
iNSPECT'tON' DATE INSPECTOR�tNSPECTi4N DATE
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