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Home My WebLink About18773 �j��,Y-c�->� � �\ CITY OF DIAMOND BAR ��,.Q_� — DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 PRES$ ��"�� BUILDING PERMIT APPLICATION FI MLY �' o DDRIESS__ ��"' � /K DATECATION !: �'� NUMB R V� , #�C _� � APN LOT TRACT D TEE �1 �`�ONST. GROUP °C OWNER � O ADDRE55��' ZONING SETBACKS QCITY'��°�jwt- , ZIP�� TEL. FRONT RW n_ APPLI ANT _ TEL. REAR ❑_ Z SIDE/SIDE STREET RW C]_ � CONTRACTOR ' SIDE n_ Q ADDRESS�� PROPOSEDUSE .A r .� �_/� � CITY � 1 ZIP �CEL. w ARCH/ENG/ Z DESIGNER w NO.DWEL. NO. NO. a ADDFIESS UNITS STORIES _�_BEDROOMS�_ � CITY ZIP TEL. � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM UNDEfl PENPLTV OF PERJVRY THAT I AM EXEMPT FROM THE CIXJTRACTORS LI- G8f8CJ9IC8fP0A W CENSEUWFORTHEFOLL(WlMGREASON�SEC.7031.SBUSINESSANDPROFESSIONSCADE:ANVCITYOR (n ZCIXINTVYN1IqiRC-0UIRES�\PERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIFANVSTRUC- W pati0/DeCk TURE.PflION TO ITS ISSUANCE.AL50 REOUIRES THE APPLICANT FOfl SUCH PERMIT TO FILE A SIGNED w STATEMENT THAT HE OR SHE IS LICENSEO Pl1RSl1ANT TO THF PROVISIONS OF TNE CONTRqCTORS LI- w � CENSE LAW(CHA7TEF 9(COMMENCING WITH SECTION 10a0)OF DIVISION 3 OF THE BUSINESS AN�PRO- � POOUSP2 FESSqN5CO0E�ORIHATNEORSHEISE%EMPTTHEREfROMANDTNEBASISFOR7HEALLEGEDEXEMV- � V TION.ANY VpLATION OF SE:CTION 70.11.5 BV ANV APPLICANT FOR A PERMIi SUBJECTS 7HE APPUCANT TO Z Re-Roof � A CINL PENALN OF NOT MORE THAN FNE HUNDRED DOLURS(5500�.): Q ❑I,ASOWNEflOFTHEPROPERTY,ORMVEMPLOYEESwITHWAGE5A5THEIR50LECOMPENSATION, 0 CDffIfIlBfC18I Z WILI DO THE YIOFiK,ANO lME STRUC7URE IS NOT INTENOED OR OFFEREO FOR SALE(SEC.7044,6U51- J � NESS AND PROFESSIONS(bDE:TME CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF � PRDPEFiTY WFiO BURDS Ofl IMPROVES THEREON,AND NMO DOES SUCH WORN HIMSELF OR HERSELF OR Q hIROUGH HIS OR HER ONR!EMPLOVEES.PROVIDED THAT 5UCH IMPROVEMENTS ARE NOT INTENDED OF m QOFFEREDFORS/LEIF,HONlEVER7NEBUILDINGORIMPqOVEMENTIS50L�WfrHINONEVEAROFCOMPLE Z TION,THE OWNEHAUILDER WILL NAVE TNE BURDEN GF FqOVING 7HAT HE oR SHE�IO NOT BUILD OR � IMPROVE FOF TNE PURPO!tE OF SALE). w ❑I,ASOVMEROFTHI=PROPEf7TY,AME%CLUSIVELYCANTRACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT TME PRQIEGT(SEG.]ON,BUSINESS AN�PROFESSIONS CODE:THE CONTRACTORS LI- V2IUfl110P1 A�J.AqEA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSOflIMPROVESTHEREON,AND - - = WIqCONTfUCTSFORSUCMPRQlECTSWITI'ACONTRACTOR(S�LICENSE�PURSUANTTOTHECONTRRF QUANTIN DESCRIPTION FEE Y TORSLJCENSELAW.). � ❑I AM EXF.MPT UNDER SEC. B.&P C.FOR THIS REASON Q � U � � DATE OWNER v W �Q UCENSED CONTRACTORS DECLARATION w CC 1 HEHEBV AFFIRM UNDER PENALTV OF PER/URV 7HAT 1 AM UCENSEO UNDER PROVISIONS OF CHAPTER � � B(COMMENCINO Wlhl SECTION 70a0)OF DIVISION 3 OF THE BUSINESS ANO PROFESSIONS CO�E,AND Z �� MY LICENSE IS IN NLL FO�CE AN�EFFECT. w� � m � UGENSE CLqSS �:,za LIC.NO. / � W � � J V DATE . WN7PACT0 d W � WORKERS'COMPENSATIQN DECLAFiATIDN � ¢ � �(�.f � I R V AFFIRAI UNDER PENA�TV OF PER1l1RV�NE OFTHE F6LLOWING�ECLARATIONS: Z / '�'- /� ` ¢ C. 0 IHAVEANDWILLMqINTpINAGERTIFICATEOFCANSENTTOSELF�INSUREFORWORKERS' _ � COMPENSATION,A3PROVIDEDBVSECTION37000FTHELABOFCADEFORTHEPERFORMANCE U - _` OF THE WORK FOP WHICH THIS PERMIT IS ISSUED. � j �� 0 J w _I HAVEANO WILlM41NTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BV SECTION Q 3]o00F THE LA80H CODE,FOR THE PERFORMANCE OF THE 1 ORK FOR WHICH THIS PERMIT IS � ISSUEO.MY WORKI�MP jF SASION INSU CE CARR �AND POIIGY NUMBER ARE: CONSTRUCTION Q > caaaiER� � �� ./ PLAN REVIEW _.. � POLICV NUM6EF_�/L�L ELECTRIC ¢ ��I'�� . . -- � �ssEcrordNE�wteEo�ErEooFn+EVEa�.rr�swaorrEHuwnEooav,as�S�roioa�Ess�. PLUMBING ^ w Z I CERTIFV THAT W�fHE PEflFOHMPNCE OG THE WORK FOfl WHICH THIS PEHMIT IS ISSUcD,I MECHANICAL �,}' SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESIJBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUlDBECAME INSPECTIONFEE _ = SU&IECT TO THE YVOFNERS'COMPENSATION PROVISIO F SECTION 3�oa OF THE LABOR — COOE.I S ALL F IRHWITH COMPLV WIT OSE P V IONS. ISSUANCE I � SMIP p DATE: e -APPLICANT: J WAflNING FAILURE T SEI:URE WOflKERS'COMPE ATIO VEflAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C _ LL SUBJECT AN EMPLOVERTI)CRIMINAL PENALTIES A�C FINES UP TOONE MUNDRED THOUSAND ENERGY PERMIT DOlLARS{f1a00o0�.INADDITION70THECOSTOF FNSATION,OAMAGESASPROYI�E�FOPIN --- J SECTION 3]OB OF THE LABJR COOE,INTEREST,ANDATTORNEV'S FEES. RETENTION FEE: ' Q d CONSTRUGTION LENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIRM UNDER PENALTY OF PERJUHV THAT THEFE IS ACONS7RUCTION LENDING AGENCY � FOR THE PERFOFMANCE()F THE WOPN FOR WHICH THIS PERMIT IS ISSUED�SEC.3091,CIV.C.). Z W � LENDER'S NAME 1=- LENDER'SADDRESS_ � ICERTIFVTMATIHAVEREI�DTHISAPFLICATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES � l � w 1 AGREE TO CAMPLV WITH ALL pTY AN�COUNTY ORDINANCES AND STATE LAWS REU7ING TO BUILDING � � d � CANSTRl1CTION,AN�HEFEAVAl1THORIZEREPRESENTATNE50FTHISCOIINT'TOENTERUPONTHE Z ABOVE-1A IONE07ROPI-R7VFORINSPECTIDNPUFGOSES. � /� " /t COMMENTS J r y�g � G� �7" �I m PERMITfEENAME PWM)� a �-, ��r_ L � � SIGNA REOF E MIT7EE D E = RECPT.NO. PAID BY VALIDATION ~ WHITE—DepaRment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Copy G�TY �F L7►IAMC3ND BAR �NSPECTIL'�N �ECt�F�D . ,� �„ i - • i � � � ! - �� t a�{ FL.fl�JR JC71ST � __ _ __. _,.__ � __ ____ — �� _._�__ . ____� f ;T�s�,,�� 3t'�E41�/��s_L _ ��_�� FHA E3EC.�MTS � F 1.r C;T€�;a` `" _ _ � _ _..i.._._._ � _��__�� _____._ _._.__------ --- ---- - -- �_.. � �F�C)Uh�� ' ` ( JNDE�i FLC3C)R C�t�CT ' _ i � m _ _� __ _— �_. _--- ,— ___. � ._____� ; �� E`��'��J�lc� � � ___ { UN��F� F�C�C�RCGI�IDU,lT _ _ _ �_ _ _ ._�.m. __ — _____ ---- _.._.___ __ �____. _ _� � �� Cz��____ _ 3 ` _....�. 1 ' �IREPLA'�� FCaUT�lC}ATION _�____�___.__ _ .._.__ _ � _ . _ � {�_._ _ _ � � �`�t'��' �'��`�'��`� ' _._w� '.� ___ � � �1REPLACE BC�Na BERM � _ _ . _._ __ _ � .__._ _ _._ ��--. .._._ llV��"�i��E�i'�9�� ' �� 11fiC�6-�T. 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NO. NO. a, ADDRESS cn - UNITS STORIES BEDROOMS � CITY __ ZIP___ TEL. _ — � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O OWNER-BWLDER DECLARATION SFWADO/REM � p I HEREBV AFFIRM LINDER PENALTY OF PERJUFY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gd(dJBlCdfpOR W CENSEL4WFORTHEFOLLdNiNGREA50N�SEC.]o31.5BUSMESSANDPROFESSIONSCODEANVCITYOR (n U COUNTYWHICHREOUIflESAPERMITTOCONSTRUCT,ALTER,IMPqOVE,DEMOLISH,ORREPAIRANYSTRUG wTURE,PFIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT iOR SUCH PERMIT TO FILE A SIGNED W Patio/Deck � STATEMENT THAT HE OR ShIE IS LICENSEO PURSUANT TO iME PROVISIONS OF THE CONTfiACTORS L�� GENSE LAW(GMAPTER 9(COMMENGING WITH SECTION 7C00)OF DIVISION 30F THE BUSINESS AND PPO� U' POOVSPd � FESSIONSCA�E)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEGEXEMP� (� U TION.ANVVIOLATIONOFSECTION7031.SBVANVAPGLiCANTFORAPEHMITSU&lECTSTHEAPPLICANTiO Z Re-ROOf A qVIL PENALTV OF NOT MC�RE THAN FIVE HUN�RED DOLURS�f5oo).): � ❑I.ASOWNEFOFTHE�ROPFRTV,ORMVEMPLOVEESWI7NWAGESASTHEIRSOLECOMPENSATION. � Commercial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.�044,BU51- J � NESSAN�GROFESSIONS CODE:THE CONTRACTORS�ICENSE UW DO[5 NOT qFPLV TO AN OWNER OF ? PROPERTV WHO BUIlDS Oq IMPROVES THEREON,AN�WHO DOES SUCH WORK MIMSELF OR HERSELF OR wTHflOUGHHI50RHEROWNEMPLOYEES,PROVIDEDTHA7SVCMIMPROVEMENTSARENOTINTENDEDOR m Q OFFEREDFORSALE.IF,HOYYL=VER,THEBUILDINGORIMPROVEMENTISSOIDWITHINONEYtAHOFCOMPLE Z TION,THE OWNER-BUILDER WILL HAVE 1 HE 9URDEN OF PRGVING THAT HE OR SHE DID NOT BUILD OR � IMPROVE FOq THE PURPOSI;OF SALE). W ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSNELYCO�TRACiINGW17HLICENSEDCONTRACTORS � TO CANSTRUCT THE PROJECT(SEC.1044.BUSINESS ANO PROGESSIONS CDDE'THE CONTRACTORS LI� VflIU8�i0f1 ADJ.AFiEA W CENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUI�DSORIMPRUVESTHEREON,AND � WHOCANTRACTSFORSUCNPROJECTSWITNACONTRACTORIS)LICENSE9PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TOFS LICENSE LAW). QCJ I AM EXEMPT UNDER SF_G ,__ B.6 P.C.FOR THIS REASON Q � O�t�� U ti � DATE OWNER H Z U � LICENSED CONTRACTORS DECLARATION w ¢ � I HEREBV AFFIqM UNOER PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9�COMMENpNG WITH SECTION]ooa)OF DIVISION�Of TN[6USINESS AND PROFESSIONS CODE,AND Z X MV LICENSE IS W FULL FORCE AND EFFECT. W �p � LICENSE CLASS�::�.e_�3 LIC.NO. _ � � �" J U DATE��(`Q�� CONTRACTOR �L(��' �,w�;6 �- W 'i 7 �rT "' (�- � WORKERS'COMPENSATION DECLARATION Q � I HEREBV AFFIRM UNDER PENALT�OF PERJ'JRV ONE OF THE FULLOWIN�UECLAHAilONS: Z Z I HAVE AND WILL MA NTAIN A CERTIFICATE OF CONSENTTO SELF-INSURE FOR WORKFRS' ¢ 2 4 COMPENSATION,AS PFOVIOEO BV SECTION 3'!0o OF THE LABOR CODE,FORTHE PERFORMANCE U OF THE WORK FOf11YHICN THIS PERMIT IS ISSUF.�. w 0 � w �I HAVE AND WILL MA NTAIN WORKERS'COMPENSATION INSURANCE,AS flEQU1RED BY SECTION O 370o OF THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FGR WHICH THIS PFFMIT IS ISSl1ED.NV WORNEHS'C-0MP NS TION INSURANCE CARRIER AND POLICV NUMBER AFE CONSTRUCTION J ►� - j cnaa:Ea 5 p .�1-u N� PLAN REVIEW � PD�ICV NUMBER__ �i h /T9 �� Z v ELECTRIC _. �G�, ¢ � (THISSECIKKJNEm�iOTBEOJMPLEfEDOFTHEPERMfTi �ORIXJ[HUNDREDDOLLARS(5100)ORLESS). PLUMBING _ W Z I CERTIFV THAT INTI/E PERFORMANCE OF T�IE WORK FOP WHICH TNIS PERMIT IS ISSUED,I MECHANICAL C,�} SHALL NOT EMPLOV ANV VERSON IN ANV MANNER SOAS'O 9ECOME SUBJECT'O THE Uj VJORNERS'COMPE�SATION�AWS OF CALIFOfiNIA,AND AGIICE TI1AT I�I SIIOVLD�ECOME INSPECTION FEE SUOJECT TO THE W()RKERS'COMPENSATION PqOVISION50F SECTION 3]DOOF THE UBOR � GO�E,ISHALLFORIMWITHCOMPLVWITHTHOSEPROVISIUNS. ISSUANCE j�� • � l SMIP p DATE _'y___�_ APPLICANT: . ___ ___ J WARNING�.FAILUFE TO SECIiRE WORKCfiS'COMFCNSATI N COV[NAGE IS UNLA' UL,AND SHA�L BE ENERGY P/C _ � SU&IECT AN EMPLOYER TO�RIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGV PERMIT DOLLARS(f100.000),IN A�DITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SEGTION37o80FTHELABONCODE.INTEREST,ANOATTORNE{•SFEES. � c.t RETENTION FEE: J � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: /, ' O ¢ I HEREBY AFFiRM UNpER PENALTY OF PEFJJFY TiiATTHEFE IS A CONSTRUCTION LENDING AGEYGV a- FOR THE GERFORMTNCE OF THE WORK FOR WHICIi THIS PERMIT IS ISSUED(5[G.3091,GIV.G.�. - �-- -�-� -- W - = LCNDCF1'S NAM[ �� ____- -' _ _ F- LENDER'SA�DRESS wICEFTIFYTHATIHAVEREACTHISAPPLICAT'�.ONAN�.^�TATETI-IATTHEABOVEINFORMATIONISCORRECT TOTAL FEES �� l � IAGREETDCOMPLVWITHAI.LGITYANDCOUNTYORDINANCESANDSTATELAWSFELATINGTOBUILDING � CONSTRUCTION,AIJDHERE',3YAViHORIZEREPRESENTATNE50FTHI5GOUNTYTOEMEflUPOM1THE Z ABOVE-MEIVTIONED PROPEf\TV fOR INSPECTION PUFPOSES. COMMENTS � (�c.',o��L� y�-�v�, -- — __ -- m PERMITTEENHME(VHINI) Q � �__ -- � SIGNATUREOFPERMITTEE �ATE = FECPT NO. _ PAID BY� VALIDATION__ ~ WHITE-De artment Co YELLOW-Finance Co PINK-Assessor Co GOLDENRO�File Co GREEN-A licant's Co P PY� PY� PY, PY. PP PY �� "�� i�� .�� ' ��': � m�� ' t i�� . wimu - � � �i��3 ( � a .� �.� r�ad�,=. "�� f !a� 3<:,��a ��'�� _ , M, �.�< ��,? "_ w"'�a"��',��e� �2 � �" a ia�(� �� .t<�?�' � ��'�i��' � �"�� '��s7`�`' - - . , , .. ., _� + � . �.„ .nn, '�'�r'`�`+`_ aa.,,,�a��,3`,rrd��, .. . ... ... ... _. _.. .... . . .. . . ,. ".; �, � ,�. � . ..... . .... . ... .. .. . ... .. .. . _.. .. _ ..._ . . ,m ,� �.��, "� .�t �-.�wr.��i"� .�,a� .. . . _ a, r w. .-,. `�' _.�».a� ... . :. . . . .. ._ .... ... . ..... ...... ..... . ..... ..... .... .. ...... . _.... . .. . . ....... . ._. . ..... _ .. .. �r��i��'�'„��ri i�i��;' s�:��e�o- _ _ _ _ _ . � ��'�t�y` "'�� ':,"'�°t _. _. ui¢� *�S � "�+' � � � , .. _. ..... . ..... . ... .. .. ....... ....... ..._. _... �� , ��'' .. _. ._ .. � ��k �� k �� p�.� �m,� �,��,� „� �� _ _ _. ` �� <<� �� ' � ��; _ _ — �� a�� `= �� "� ��'' _ � �`� ��%�� t �� Q � �� _ �� ,� �� . � � � _ _ _ _ �.2�f � ofi�i� .� ��,E��: , ,-°., ��;A. ._a b . ..g•� -�. CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 BUII,DING PERMIT APPLICATION PRESS FIRMLY JOBSITE�. /rc ADDRESS�f APN LOT TRACT OWNER ADDRESS��' CITY-wt-ZIP��TEL. APPLI ANT TEL. CONTRACTOR ADDRESS�� CITY 1 ZIP�CEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLCNNING REASON(SEC. 7031.5 BUSINESS AND PROFESSK)NS CODE:ANV CITY OR COUNTY WHICH REQUIRES�\PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV 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- FESSgNSCODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIS FUR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SE':CTION 7031.5 BV ANV 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 MY EMPLOYEES W ITH 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 CbDE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS Ofl IMPROVES THEREON,AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR THROUGH HIS OR HER OW?)EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF,HONIEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF(X)MPLE- TION,THE OWNER-BUILDEIi WILL HAVE THE BURDEN GF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ 1,AS OWNER OF THI: PROPERTY AM E%CLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHD CONTRACTSEOR SUCH PROJECTS WITHACONTRACTOR(S)LICEHSEDPURSUANT TO THE CONTRAC- TORS DCENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. &RO FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER B(COMMENCING WITH SECTKKJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FO ICE AND EFFECT. ('� �W I C � LIC NO L CENSE LASS DATEIAA �CONTRACTO / 'WORKERS'COMPENSATION DECLARATION Y gFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATKNA,A'3 PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOP WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE 1 ORK FOR WHICH THIS PERMIT IS ISSUED. MV WORKI--RS f".OMP�F SATION INSU CE CARR I AND POLICY NUMBER ARE: CARRIER POLICY NUMBER_ (IFIIS SECTlON NEST: NOT BE OCI«PLEfED OFTHE PERMT IS FOR ONE HIJfDRED DOLLARS(E1f10)OR LESS). I 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'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE YVORKERS'COMPENSATK)N PROVISK)F SECTION 3700 OF THE LABOR CODE. I S ALL F RTHWITH COMPLY WIT OSE P V IONS. PPLICANT DATE: e -A WARNING: FAILURE T SECURE WORKERS'COMPS ATIO VERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES A D CI FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000),IN ADDITION TO THE COST OF ENSATK)N, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE RE/1D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE CTK)N PURPOSES. ABOVE-M TK)NED PROPIERN FOR INSPE J PERMITTEE NAME PRINT) � �� --„rte I�v SIGNA RE OF E MITTEE r 0 0 0 w S z 0 0 w 0 w a 0 W U Z W Sig V U H Z W Z 0 d W 0 U w ul Z� Q W Q Q W Z C7 (n 1--= W J LL J Q W d O d Z W f--- Q W Z Q m WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy CITY OF DIAMOND BAR INSPECTION RECORD INSI�'ECTlON DATAINSPEGTC}R FLOE�R JUIST I j FHA REC�MTS I UNDER FLOOR DUCT -�-r- DATE L�I UNDER FL00 CONDUI I H FIREPLACE FOUND�T EAM 1 1 1-:-)PP:AhA 81-T FOND BEAM MID HT BOND BEAM PHF-C-.. �3?�I VG (BFh(t�', F=i (7'_ F�s�da��-=,;Cllu�a P00]. �-LLCTRIC � L FENCING 0-0 PC�;,_F1NAL - ��,; E Imps. <'ATIQNS INSPECTt}R X� .r-c--�, CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY ADDRIESS?6"V�, 1�� APN LO TRACT OWNER ADDRESS�tJS' �t�i CITY(��ZIp�!��TEL. APPLICANT_TEL. b CONTRACTOR J � �� Y ADDRESS T� � CITY Wwl �.w�ZIP 4 r 1 e.n TEL. P9- ARCH/ENG/� DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE IAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSIN ESS AND PROFESSIONS CODE:ANV CITY OR COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC- TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR ShIE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO- FESSIONSCODE)ORTHAT HE ORSHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MCRE THAN FIVE HUNDRED DOLLARS(t500).): ^ I,AS OWNER OF THE�ROPERN,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 Oq 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 W(THIN ONE YEAR OF COM PLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSI;OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCTTHE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE'THE CONTRACTORS LI- CENSE IAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS W ITN A CONTRACTORIS)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). CJ I AM EXEMPT UNDER SF_C. ,_B.t P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HERERV 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 MV LICENSE IS IN FULL FORCE AND EFFECT. ,�„,�7 LICENSE CLASS ��',��,,4.�3 LIC. N0._�fT�3 Y.V I DATE�/)��CONTRACTOR�L(��' �,w�;�� J77� �- WCIRKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MA NTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR 1VHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MA NTAIN WORKERS'COMPENSATION INSURANCE,AS fIEQU1RED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MV WORKERS'CO MP NS TION INSURANCE CARRIER AND POLICY NUMBER ARE: C CARRIER f� p POLICY NUMBER_�i o/7 (THIS SECTKXJ NEED NIOT BE COMPLETED OF THE PERMRI FOR ON[HUNDRED DDLLARB(5100)OR LESS). I 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'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT: WARNING: FAILURE TO SECURE WORKERS'COMPENSATI N COVERAGE IS UNLA UL,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 ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HERERV 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. 3097,GIV.C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE REAC THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE TO COMPLY WITH AI-L CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HERERV AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPEFIN FO R INSPECTION PURPOSES. Ij �� PERMITTEE NAME(PRINT) SIGNATURE OF PERMITTEE DATE WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy