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Home My WebLink About17523 (10) _`�� C1TY OF DIAMOND BAR �� DEPARTMENT QF C(3MMt_INTTY&,DEVELOPMENT SERViCES 21825 E.Copley Ihive pRESS {909)860-3195 Fax(909)861-311'] '�-.�� BUILLIING PERMIT APPLICATIC/N FIRMLY JOBSITE 4 APPLICATION � ''� 2,,`,�,. ' PERMIT �''�� o ADDRESS_��"��.�� 4ATE____t__ c7�_ `�✓1 �� rNUMBER�'� � � � a ISSUE TYPE OCC CO APN ��-�CT DATE CpNST. GRC?l7P p OWNER �` ' L�"'3 1' o ADDRESS . • ZONWG SETBAGKS z CITY �1,,, Z� TEL. FRONT RW ❑ APFL AN T�t. REAR C� a — SiDE1SIpE STREET RW ❑ _ ¢ Ct3NTRACTOR�� ;� t'-/�� SIDE ❑. � ADDRESS�.,;�,_,�,��_±? PROPOSED USE � CIN ZIP,__� TEL. w ARCHlENGt ! � DESIGNER �� ' f T' NO.DWEL. NO. NO. a ADDFtESS � UN1TS STC?RIES BEDftOOMS � CITy,,,�S iu'�e ZIP TEL. � DESCRIPT{ON SQ.FT. FACT4R PSF ADJ.AftERNAIUATlON � 4WNER-BUIIDER DECLAftAT10N SFRlRDD1REM O (� t HEREBY AFFIRM UND'eR PENAITV OF PEHJUFlY 7HAT I AIA EXEMPT FR4M THE CON7RAC70R5 LI. � Garage/Catport W CENSELAWFORTHEWLIOWMQflEAS(7M(SEC.7o3f.5HU51NE5SANDPRdFESSF'�NSC06F;ANYCITYOR C7 COUNTVWHICHREOUIRE5APERMITTOCONSTRt1GT,ALTER,�MPRdVE,DEMOLISH,ORREPAIpANVSTRUG- W pytltl/DeCIt � TUflE,PRiOR TO iTS ISSUANCE.A150(iE4U�ftES TNE APPUCAN'f FOR SUCH PEW��11T TO Flt,E A SIGNED � � uTATEMENT 7NAT HE OR SNE�5 LICENSED PURSUANT TO"iiE VttOVi5iON5 OF THE COt�17'PACTORS Li� � GENSE LAW(CHAP7ER 9�C6MMENCINfi WITH 5ECT0.7N 7W0)OF pIVI510N 3 OF THE 6USINESS AND PRO- � PODUSP2 � FESSbNSCODE)OftTHATHEOftSNEiSE%£IUPTTHEREFf3C7MANC}THEBASISFOftTHERILEGEDEXEMF- � � TION.AIVYVIOLATIONOFSEI:TION7o31,6BVANYAPP4.ICANTFORAPERM1i5U8JECT5TNEAPPLiCANiTp Z R0-ROOf � ACIVII PENAI.TY OF NOT MC�flE THAN FNE HUNDRED DOLLARS(5500),I' � OLASOWNEROFTHEPflOPERTY,OftMYEMPt(?YEESW§iHWAGESASTNE.'P,SOlEC6MPENSATI4N. � {',pmfi2lCidl ,—.`. WILL W THE WORK,AND THE ST'RUCTURE 15 NOT�MENpED OR OFfERED FpR SALE(SEC.7044,BU51� J NE55 AND PflOFESSiQNS GJDE:iHE CQNTlAGTORS LlCENSE LAW DOES NOT APGIY TO AN nWNER OF � PROPERTVWHOBUILDSORIMPqOVESTHEREON,ANDWHODOE55UCHWOiiKHiMS6tFOR4ERSEt.FOft � (� THROIIGH HIS OR HER OWN EMPLOYEES,PR(7VIDEP THAT 5UGH IMPftOVEMEN75 ARE NOT INTENOEU OR m ,W�, OFFER£4FORSRI£.iF,4iOW£VEF{,THEHUILDtNG�F1MPR6YEMEN'"15541OWITFNNONEYEAROFC4MPLE� � TION,THE OWNER�9UILDEF,WILL HAVF iHE BUflDEN OF PROV�NG TIiA�HE QR SHE DID N05 BU�ID OR � IMPROVE FOR THE PURPOSE OF 5ALF). � ^,,,,, Ll I.AS OWNER oF T?iE PAOPERiY,AfA£XCLU5NELY CONTRACT�JG WITN UCENSE4 GONTAACTORS � � TO CANSTHUCT TME PRpJLCT ISEC.�aba,BIISINESS ANp PROFFSSIONS CODE:THE CONTRACTOqS Li� VdIU8l10r1 ADJ.AREA LLl CENSELAWOOESNOTAPP�YTOANOWNEaDFAPROGERTVWHQBUILDSOFIMPRQVESTHEPEON,AND -� � WHOC6HTflACS5FOR5UCHPROJfCT5WtTHACONTRAGTpR{SjtiCE�USEDPURSUANTT4TNECONTRAC� QUAPITYTY t}ESCRIPTIdN FEE Y TORSLICENSELAW.). v J �}' (�!1 AM EXEMPT UNOE9 SEC, p.8 Q.C.FOR T4it5 R'eA Q y''S _-- U W � DATE OWNER _ V � W � LICENSED CONTRACTORS DECLARAT�ON w d [C I HEREBY AFFIRM UNDER FENAI.TY OF PERJUR�'iHAT i RM IiCENSE�UNDER AROVISIONS OF CHAPTESi � � 4�COMMENCINGWITHSECTION7000)OF�IVISION90FTHEBUSINESSANDPROFESSIOASCODF,AN� z �X MY IiCENSE�S ibl FUtt fQi�CE AN�EFF£CT m p IiGENSf Gl.hSS i, , lIC.NO. ... ..— � U DATE_.,. _ GONTRACTOR`_�.�.—_—.. �- W � V1lORKERS'COMPENSATIQN LIECLAFATION � Q � U � I HEFEBY ALFIfiM UNDEF PENAITV OF PEFlJURY ONE OF iHE FOILOWiNG DECIAflATIONS: Z Q O i HAVE AND Will MASNTAIN A GEATIFICATE OF CCSNSENT TO SEI�-�N$l1RE FOR 45Y}RKERS' S � COMPENSATION,AS PROVIDED BY 5ECTIpN 3�ao OF 1NE LABqR CODF,FOfl THE PERFORMANCE w of 7H£WORK FOH WNtCH TNIS PENMIT IS�SSUEp. c� � W IHAVEANDWILIiNAINTAINWCIPKERS'COMPEN5ATIONINSURANCE,ASREC]UIREDBVSECTION � �,.. p 37UR t}F TNE LA6'>R CQDE,F6R THE PERFt7RMANCE OF TH'c WORK FOR WHtGFi TH�S PEflMkT 15 — ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CONSTAUCTION j cqRqieR_.___ . . � Pl.AN ftEYIEW I`��5�3 �. �j - z QoucrNu�usER ELECTRIG � ¢ Q {iHI55EC'f10NNEIDN�7BECOMPIETEDOFTFIEPERMITISFORONEHUM1TJREDp'.7LLPi1S(5100)Of1LE55)- P�UMBING s^"�'i� � ., w MECHANICA � �' Z I CERTIFV THAT IN TME GERFCIRMANCE OF 7HE WORK fOR WHICH'fHIS PEflM1T IS ISSUEU.I ----- --�— �} SHALLNOTEMP',.4YANYPERSONiNANYMANNEFlSOASTOBECOMESlI6JECTTOTHE � WORKER$'COMPENSATIONlAWSprCAI�FORNIa.A4UAGftEETNATiFIS}NJVtOBFCOME 1NSPEGTVON E. . � SU&IECT TO THI:WOHKERS'COMPENSAI IfJN PROVI510N50F 5ECTION 3]DOOF TNE LABOR �SSUANCE .. �..— COOE,t 5NAlL KOflSNW�7N COMPI.Y WITH THOSE Pft4YtStoN5- O SMIP _ p DATE:_ .._ APPLICANT: _ � w ENERGY PJC J WARNING�FAILURE TO E��ECURE WORHEFiS'COMPENSATION CqVLRAGE IS UNLAWFU�.ANb SHALL BE """'—" � � SUBJECTAFI£MP7.OY€P50CRIhfiNAIPENALTiESANOGVILfWESU�I�QNENUNDREDTHOUSAND � OOILARS�S1a0.P00).�N AD�ITION TO THE COST OF COMPENSATION,OAMAGES AS PROV16Efl FOR iN ENERGY PERMIT .. � SECTION37080FTHELABORCODE,INTEREST,AN�AlT(7RNEV'SFEES. RETENTIONFEE: , . .. .�—....—. w CONSTFUCTIpN LENDING AGENCY pRE-ALT FEE: d �--�rr-'�---'-:�i-f=-��- O � � I NEREBY AFFIRM IIN�ER PENALTY OF PERJUR�iHRi THEflE IS A COhSTRUC7ION tENOiNG AGENCY _ FOR THE PERFORMANC�,E OF TNE WORH FQR WHICH 7HI5 P=HMR IS ISSUEC(SEC.8ow,CIV C.�, Z W � LENDER'S NAME_.. . .. -��--�� -- F- LENbER'SADDRE55_ _... - — ;^� _, (�7 � � � WICERTIFVIHATINAVEREA�THISAPPUCATIONANDS7ATETNATTHEAeOVEiNFQRMATKMiSCAftRECT. Tll IAL FEES '`��,! � I AGREE TO COMPLV WITH ALL CITV AND COUNTY OR�7INANGES AND STFTE IAWS RELATING Tp BUILDING �� CONSTRUCTION,AN4 HEREBY AUTtiOft4ZE ftEPRESENTAT{VES O�TMS GOUNTY TO ENTER JPON THE lj�J ZAf30VE�MENTIONED PFIOPERTY FOR IkSPECTION PURPOSES. COMMENTS��-�^ .--.--._— � J . � _. ._� � ... . — m PERMiTT£E tJAME{Pi1M} 1 ^ Q' � �l.. t -... .... .. - C!) � — � SiGNATUREOFpERMiii E 4:' 6ATE PEGPt NO. PAID 8Y VAlY4ATION 2 T ~' WHITE—De ertmeM Co YEIC W—Finance C FY.�fl�DENROD—Fite CQ f REEN— IicanYs Copy p py, Opy,PiNK—Assessor Co py. T . �� _ �:�._ . -. � ��d � ��„��x� � °;° � , . �� -'�� : Si�C.� ru°,r4.�c.�s��W ivcoKduzcc •t •'�`�' t�c�� B�F� _A�' ..�� 3 `�oL _ i•�3•,�:_ ';c !�.n�,�`t C��u-ua:;:� ��2tc.��-tccs�-�' — ^'�rC t�J r� _ , r: _ , r-, . , � �;� � _ _ � �� p�� ,� � � _ _ �6 z t.�a � ��,��;• _ _ _ _. _ •�, , � ��.� � � � 4 :, � � . . � ; � , � � . � n ; . _ _ .,� T� � �� , , � , . , _ u� . .� �, � , ,�� .� � , �.. v ;t � � �� n rF � ,, � '. _ � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&. DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-311'7 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE L� ADDRESS APN LOT RACT OWNER �� L ADDRESS CITY'1 Z�y�TEL. �� TEL. APPL A CONTRACTOR� ''/� CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS� CITY�,y�ZIP TEL. 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 COD E:ANV CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC- TURE,PRK)R TO ITS ISSUANCE,AL50 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 PR6 FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): ^ I,AS OWNER OF THE PROPERTY,OR MV 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,HOW EVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE V EAR OF COMPLE- TION,THE OWNER-BUILDEF',WILL HAVE THE BURDEN OF PROVING TIlAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE. PROPERTY,AM EXCLUSIVELY CONTRACTlNG 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 WHO BUILDS OR IMPROVES THEREON,AND WFiO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS LICENSE LAW.). ^ I AM EXEMPT UNDE9 SEC. B. 8 P.C. FOR THIS REAS j DATE OWNER- LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY TNAT I AM LICENSED UNDER PROVISKKJS 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 LICENSE CLASS LIC. N0. DATE CONTRACTOR NIORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL IAAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL INAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION 3700 OF THE LABIJR 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 NEID NOT BE ODMPLETED OF THE PERMIT IS FOR ONE HUNDFIED DOLLARS(E100)OR LE55)_ 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'COMPENSATON LAWS OF CALIFORNIA,AND AGREE THAT IF I SHCKILD BECOME SUBJECT TO THE: WORKERS'COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR LADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. I 1 DATE: APPLICANT: I I I WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE SUBJECT AN EMPLOVEP.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 37080E THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY i I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.). 1 LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INPoRMATION 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 3 ABOVE�MENTION ED PFIOPERN FOR INSPECTION PURPOSES. J D PERMITTEE NAME(PR.NT) 31; l -�SIGNATURE OF PERMITT E�.;'DATE WHITE-Department Copy,YELL W-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy SCECL to°,T4u-4TodJ tv cr Kduz to t :mot f&... 4'P o A�A'�5 I °3;t!�r. CRa �-u "NUF,tcc��- ^ktjlzfi)