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Home My WebLink About15111 (17)1.111118 BAR 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 l � 7 1 �d zwZ = APN LOT TRACT OWNER ADDRESS CITY V�I AVL ZI 7 �& TEL.1$ %"' APPLICANT TEL. CONTRACTOR ADDRESS SES + 1 CITY LnMLb& !'it2r-`1 ZIP tr TEL- �t`ZC7 ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFRRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC.7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, OR REPAIRANY 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 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL 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 FORSALE IF HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE. TION, THE OWNER- BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW DOES NOTAPPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). ❑ IAM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 114ERERYAPPIRM UNDER PENALTY OF PERJURY THAT IMA LICENSED UNDER PROVISIONS OF CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE DLISINESSAND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE e°c�--1� CONTRACTOR . WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _ I 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. 1 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 15 ISSUED. MY WCH RS' C(kAPENSATiON INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER �= POLICY NUMBER 6 F3L1— (MLSSECTION NEEDNOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DDLIARS ($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' COMPENSATIO ,8gY1�NS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY'HOSE PROVe 15i01V� DATE: C-�- 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 (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. C.). LENDER'S NAME LENDER'SADDRESS I CERTIFY THAT IHAVE 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 HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE NAME SIGNATURE OF PERMITTEE "- - DATE PRESS FIRMLY PPL /C DATEICATIO NUMBER .r,i #PERMIT i ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM 1) Garage/Carport WPatio/Dock LL Pool/Spa 0 Z I Re -Roof � Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U <r F U W J w (D m CIL U_ Z I C 2 LULL CONSTRUCTION PLAN REVIEW ELECTRIC 77.� PLUMBING V MECHANICAL INSPECTION FEE ISSUANCE- SMIP ENERGY P/C ENERGY PERMIT o &. M 'I RETENTION FEE: PRE -ALT FEE: v rr/ - Jw l�3 prr iia -`a s' a TOTAL FEES COMMENTS RECPT. NO. 146 1,—` PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, (#OLDENROD—File Copy, GREEN—Applicant's Copy