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Home My WebLink About14981 (17)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES c 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS _ of JDy `'�o��Q-P) APN LOT TRACT OWNER b- ArH NfLY ADDRESS SA-MhC CRY ZIP TEL APPLICANT TEL CONTRACTOR S `13.15AL.S CMe, Zt./l ADDRESS 101V 1 L-uDQ G CITY S• P'S• ZIP TEL O D7�oj ARCKENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION S HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FP.OM THE CONTRACTORS L4 CENSE LAW FORTME FOLLOWPLO REASON (SEG 7071.5 SUSNESSAND PROFESSIONS CODEANY CRY OR COUNTYWHICH REOIRRESA POWrTTOCONSTRIRT,ALTER IMPROVE, DEMOUSK OR REPAIR ANYSTRUO. TURE PRHOR TO ITSISSUANCE ALSO REQUIRES TME APPLICANT FOR SUCH PERMIT TO FRE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- CQISE UW IQIAPTER 8 (OOMMENCI N7 WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO. FESSId1S CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP• TION, ANY VIDUTIONOF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUWECTS THE APPLICANT TO ACWX PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (11500t)c O LAS OWNER OFTHE PROPERTY,ORMY EMPLOYEESWITH WAGES ASTHEIR SOLE COMPENSATION, WILL DO THE WORK. AND TME 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/ WORKHMSELFOR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFFEREDFOR SALE IF, HOWEVER BUILDING DING OR IMPAowmENT 6 SOLD WITHIN ONE YEAR OF DOMPLE• TON, THE OW NERaUILDER WILL HAVE THE BURDEN OF PROWp THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSEOF SALE). O L AS OMNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 700, BUSINESS AND PROFESSIONS CODE: THE COMMCTORS LH CENSE LAW DOES NOTAPPLY 70 AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WNOCONSMCTS FORSURI PROJECTS WIT1A WNTRACTOR(S) LICENSED PURSUANT TO THE OONTRAG TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC. B. { P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFI M UNDER PENALTY OF PERJURY THAT I AM LICENSED UPIDER PROVISIONS OF CHAPTER PO 8 (COMMENCWITH BECTON 7000) OF OMSON S OF THE BUSINESS AND PROFESSIONS CODE AND MY LICENSE IS N FULL FORCE AND EFFECT. j LIC CLASS LIC. NO. 72(—Lei CONTRACTOR WORKERS COMPENSATION DECLA A ON 1 HE ESYAFFM.1 UNDER PENALTY OF PELUAY ONE OF THE FOLUO E RATIONS: —I HAVE AND WILL MArFTAN I A CEM MATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 7700 OF ME LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _7f1 HAVE AND WILL MAINTAIN WORKER'S COMPENSATION INSURANCE, AS RECUIPED BY SECTION 3700 OF THE LABOA COO£ FOR THE PERFORMANCE OF THE WORK FOR WHCH THIS PE1MR 15 14911EA MY ��qpN R5 COMPENSATION INSU/R�AN�CE CARRIER ARA POLICY Nl1MBERARE IEA�- LRA/NUMBFR SECT/]NPE®NDTBEOCR.fiFTEDOFnE PEFR5T6 fiAONEHAOFLT DGLI./U8 (SILOJOALtSS). 1 LEIRIFYTMT LATHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SAiNl NOT EMPLOY ANY PERSON N ANY MANNER SO4A111OECOME SUBJECT TO THE WORKERS'COL1PFlISATONUW9 OF CAl1 RANTMTIF IBIfOAO BECOME S1IRIEGT TOTHE WCMXERS.C( PENSAT ROWSSECTION 770006 THE LABOR CODE I SHALL FORTTMWIT/ COMPLY WITH E P DATES4% btlbtl APPLPCAM: WARNING: FAILURE TO SECURE WORKER4'tXOMPE SA IdUW AGE IS VNLAWFIL, APA SNALL SE SUBJECT AN EMPLOYER TO CRIMPAL PENALTIES OCIVL FN PTO ONEIMRDREDTHOVSAND DOLLAAS If 100,000), N ADDITION TO THE COST OF ENSATIDN, DAMAGES AS PROVIDED FOR IN SECTION 7708 OF THE LABOR CODE INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIMUNDER PENALTY OF PERAIRY TMTTMERE IS A CONSTRUCTO) LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (S EC. 7007, CIV C.). LENDER'S NAME LENDERSADDPESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS ODRRECT. I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATNO TO BOLDING CONSTAMOK AND HEREBY AUTHORIZE REPRESENTA7WES OF THS COUNTY TO ENTER UPON THE MENTIONED PROPERTY FOR INSPECTION PURPOSES. �A PERM ENAMEL SIOM FPER TT DATE ®r PRESS FIRMLY APPLICATION PERMIT �LI P/C / �� DATE Q NUMBER_�� tt ISSUE DATE S`� 0'�G TYPE CONST. OCC GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE I NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFRIADDIREM (40 Garage/Carport WPatio/Deck L= PooVSpa ZRe -Roof 0 Comment Ln .'1 Valuation 1 ADJ.AREA QUANTITY DESCRIPTION FEE J Q U 2 U Q W W z 2 LD J a Q V Z Q U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE .i O� SMIP �� d ENERGY P/C ENERGY PERMIT RETENTION FEE: v PRE•ALTFEE: f�tr_flr Y r r ^" Y r144a TOTAL FEES " b& COMMENTS>>+. RECPT. N0. PAID BY _ VALIDATION V V WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—App cant's Copy