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Home My WebLink About15015 (17)U1,1�1111U U,1h-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 G i /A/T 2A_ _ APN LOT TRACT _^ OWNER ADDRESS Al 110FIA_ CITY/�M1C1p �iAk— ZIP TEL. APPLICANT TEL. CONTRACTOR �j�f/i1l pQ ADDRESS CITY "liw tth ARCWENG/ 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 PF40FESSIONS CODE- ANY CITY OR COUNTY WHICH REOIJIRESA PERMITTO CONSTRUCT, ALTER, !MPRDVE, DEMOLISH, OR FIEPAIRANY STRUCG TORE, 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 CONI RACTCRS LI CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OFTHE 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 (SSW).): CI I. AS OWNER OFTHE 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 BURRS 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 COMPILE. TION, THE OWNER -BUILDER WLL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FORTHE PURPOSE OF SALE). O LAS OWNEROF THE PROPERTY,AM EXCLUSIVELYCONTRACTING WITH I!CENSED CONTRACTORS TO CONSTRUCT THE PROJECT ISEC. 7044, BUSINESS AND PROFESSION$ 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 ACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAG TORS LICENSE LAW.). O IAM EXEMPT UNDER SEC. B, 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM 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 FORCE AND EFFECT. LICENSE C 11 S� LIC. NO.____,__,,,_ DATE �___ CONTRACTOR21 1f�m WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PCCODURY ONE OF THE FOLLOWING DECLARATIONS: ---I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE !-OR WORKERS' OAMPENSATION, AS PROVIDED BY SECTION 37000E THE LABOR CODE, FOR THE PFRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _ I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS HEQU!RED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WFIICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (iWSSECTICN NEED NOT BE COMPLETED OFTHE PERMIT 0 FOR ONEHJI.OREDDOU kRS (5100) ORLM3 I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO OEC^AME SUBJECT TO TI IE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE. THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' OCMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR �EVIFITH COMPLY WITH THOSE PRDATEAPPLICANT:WARNINE 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 3708OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OF HE WORK FOR W4 CH THIS PERMIT IS ISSUED (SCC. 3097, CIV. C.). LENDER'S NAME_[' LENDLR'S ADDRESS !�/y�}'�-�'✓--�""�l_ "y`�3 CERTIFY THAT I HAVE READ THIS APPLICATIONAND STATE. THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCESAND STATE LAWS RELATING 1'0 BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED P PERTY FOR INSPECTION PURPOSES. PERMITTEE N E ( INT) SIGNAT E F PEI PRESS FIRMLY APPLICATION -,? !q PERMIT / ] ,C1 - �P/C DATEI. V tJ NUMBER a ISSUE a ,. „ I�pE OCC DATEf CONST. — GROUP ZONING SETBACKS FRONT RW f1 REAR IJ SIDE/ SIDE STREET RW M _ SIDE PR POSED USE �IOtGS�-�i. NO. DWEL. NO. NO. , UNITS STORIES _ BEDROOMS DESCRIPTION Q FT_ FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport UJ W Patio/Deck ____ LL Pool/Spa Z Re -Roof p Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U CC LLI LU 0 Z _ _ m 2 Z 2 W CONSTRUCTION PLAN REVIEW ------... l ELECTRICll- PLUMBING 't1�� MECHANICAL ___._.-.__ ..: •,";.._--_ _ INSPECTION FEE ISSUANCE'S SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT.No.. PAID By _�VALIDATION_ WHITE--Departmfnt Copy, YEI.IIOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy a ;, .:;