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Home My WebLink About15118 (20)J CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION FIRMLY 1 CPLtO CRCE iIIVE OWMCl�O 6°� ADDRIESS APN LOT +34 •_ TRACT ��I OWNER NtMq L LiCA1JA ADDRESS tl ccoo CITY QLAW0 ZIP 1111GS TELA-2 APPLICANT TEL. CONTRACTOR ,ADDRESS CITY ZIP TEL ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS U CENSELAW FOR THE FOLLOA'NG REASON (SEC. 7071.6 BUSINESSAND PROFESSIONS CODE ANY CITYOR OCU NTYIYIBOI REQUIRESA PERMRTO CONSTRUCT.ALTER IMPROVE, DEMOLISH, OR RE-FI-3— TUBE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE UW (CHAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO4 FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION. ANYVIO ATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ANY A CML PENALTY OF NOT MORE THAN FIVE DOLLARS (S 500)X D LAS OWNER OFTHE PROPERTY.OR MY EMPLOYEES PATH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 70,14, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UDOES ES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDSOR IMPROVES THE FIRM, AND WHO DOES SUCH WORK MMS ELF OR HERSELF OR TMFOUON MS OFF HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT N700ED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEVENT IS SOLD WITHIN ONIEYFAqOFCOMPLE TIONI. THE OWNER-BURDER WILL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} ❑ L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTAACTND WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 701. BUSINESS AND PROFESSIONS OOOE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TOAN OWNER OFA PROPERTY WHO BURRS OR IMPROVES THEREON. AND "CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). O IAM EXEMPT UNDER SEG B. a PC FOR THIS REASON DATE 1 OWNER tZ �r LICENSED CONTRACTORS D LARATION 1 -AFFIRM! LANDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER (COMMENCNO WITH SECTION 700D) OF DIOSION S OF THE BUSINESS AND PROFESSIONS COLE, AND MY LICENSE IS N FULL FORCE AND EFFECT. LICENSE CUSS LIC. NO. DATE CONTRACTOR WCRKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: HAVE AND WILL MAINTAIN A CERTIRCATE OF CONSENT TO SELF -INSURE FOR WORKERS _I COMPENSATION. AS pnowro BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEMOT S ISSUED. I I HAVE AND Nlll MAINTAINWORKERS' COMPENSATION INSURANCE. AS REWIRED BY SECTION ' LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 3700 OF THE ! ISSUED. MY YORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER I POLICY NUMBER (DK SECTION NE® NDT SE DJF.RE!ED OF TI E F UM IS FOR ONE I4RUED DOLLARS (SIM OR LE M I CERTIFY THAT N THE PERFORMANCE OF THE YORK FOR WHX7RTHIS PERMIT S ISSUED, I j SHALL NOT EMPLOY ANY PER" N ANY MANNER SOAS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME - SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3TOO OF THE LABOR _I SHALL FORTHWITH COMPLY WITH THOSE PpOWSKOIS. j CODE � DATE: APPLICAM: J WART NO: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT ANEMPLOYER TOCRIMINAL PENALTIES AND CIVIL FINES TO HUNDRED D ASPR p0(LARS (f 100,000),NADOTION TO THE FAST OF COMPENSATION,. DAMAGES AS PROVIDED FOR IN J SECTION 7701 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. 3 CONSTRUCTION LENDING AGENCY _ Y 1RPENALTYOF T ACOSLENDNO AGENCY FOR THE PERFORMANCE OFTHEWORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097, CIV C.)- 3 - LENDERS 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 L CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ' APOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES - Hum SYN y2vow, PERjTTEX NAMErorm .` V , 406 SIGNATURE PEPMOT,1 E DATE C QUANTITY APPLICATION /n DATE (Y I PERMIT / / P/C D� . / N3 ISSUE _ d TYPE OCC 1 DATE �J �i CONST. GROUP ZONING SETBACKS FRONT RW 0 REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIeTION SO. FT ACTOR PSF ADJ.AREANALUATION SED ADD EM � GaragelCarpori LUPatio/Deck LL PooUSpa ZRe -Roof 0 Commercial - - m VahJati. ADJ.AREA QUANTITY DESCRIPTION FEE U jY U W J W CT. 2 ED J a Q U QZ 2 W CONSTRUCTION u PLAN REVIEW y ELECTRIC PLUMBING MECHANICAL � .I INSPECTION FEE ISSUANCE ME cy SM1P e_5 . ENERGY P/C ENERGY PERMIT c1 t L' RETENTION FEE- iS l LN U i LI'. .J• ` U PRE-ALTFEE: TOTAL FEES ' J /% { IU COMMENTS L'►f RECPT. NO. PAID BY _ VALIDATION WHITE—DepartrAent Copy, YELLOW—Finance Copy, PINK—ASSASSor UM. UvWrNnvv—rlln L -VY, cl.— WV— PY