HomeMy WebLinkAbout18120 (23) CITY OF DIAMOND BAR
-�`` DEPARTMENT OF COMMUNITY&DEVELOP1v1ENT SERVICES '
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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
JOBSITE
ADDRESS-2809 CRYSTAL RIDGE ROAD
APN LOT 27 TRACT 47950
OWNER Diamond Bar West
TTC
ADDRESS 3480 Torrance Blvd.t i00
CITY Torrance zip 90503 TEL.31 0-540-399
APPLICANT Richard Gould TEL.s ma
CONTRACTOR .TCC Constructinn
ADDRESS same as owner
CITY ZIP TEL.
ARCH/ENG/
DESIGNER R. Gould&Assor.
ADDRESS same as owner
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 PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY 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-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION.ANY VIOLATION OF SECTION 7031.5 BYANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,AS OWNER OF THE 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 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,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT 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-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM 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 CLASS R LIC. N0.67198
2
DATE CONTRACTOR JCC Construct o
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
X I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER State
POLICY NUMBER 16044 700
(THIS SECTION NEED NOT BE ODMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY 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 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),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 HEREBY 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,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
1 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
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PE AME(PR T)r.�
SIGNATURE OFPE EE D A T E
APPLICATION I5 c Z- PERMIT-/j }1, P/Ce_9 2-
DATE NUMBERf�� #
ISSUE TYPE OCC
DATE CONS,GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE New Single Family gesidpnep
N0. DWEL. N0. N0.
UNITS 1 STORIES 2 BEDROOMS 6
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
FR/ADD/REM 7.588 -7,1 (13 LI 0
Garage/Carport 790 G
W Patio/Dock- 203 G
LL PooVSpa
Z Re-Roof
0 Commercial
Balcony
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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I-
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w
W
a
Z
IL
Q
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2
0
w
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CONSTRUCTION
v
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ELECTRIC
PLUMBING 0. -
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS 1 � t.1/,C,
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
,'y3'e7z itsc�XZA-� �'�Zc,-S/t+S 40.14
-3--Qt. -Tb k4wCtQLLcit00J FO 5 ir+34�-5ac*,Z.•fit Qeq loo,txxZce
DIAMOND BAR i
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)969-3 95 Fax(909)861-3117 13 39•-7 0 0 0
BUILDING PERMIT APPLICATION
JOBSITE
ADO„
DRESS
APN LOT TRACT
OWNER
ADDRESS
CITY TEL
APPLICANT T L.
CONTRACT R e L
ADDRE
CITY ZIP TEL.
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 LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSNESSAND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT ALTER.IMPROVE. DEMOLISH.OR REPAIRANY STRUC-
TURF, 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-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 70315 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
0 L AS OWNER OF THE 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,BUS)-
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,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 LAS OWNER OF THE PROPERTY AM EXCLUSIVELY 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 OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC.
TORS LICENSE LAW).
0 I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCNG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS N F FORCE AND EFFECT.
LIC. N0. '�
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARA ON
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS
E
PROVIDED BY SECTlON 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
H
WORK FOR
THE WORN FOR 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 WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORSE S COM NSATI)N INSU CE CARRIE D POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
ITHISSECTI N NEED NOT BE 00 OFTHE PERATE FOR OPE DCUJVY'(5100)ORL
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SU&IEC TO TH
RS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
E.1 F H COMPLY WITH THOSE SIGNS.
t
DATE: ICANT
WARNING: F URE T SECURE WORKERS'COMP ATION COVERAGE IS UNLAWFUL,ANDS Cf
SUBJECT AN PLOY R TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED T D
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVID IN
SECTION 3708 OF THE LABOR CODE. INTEREST.AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY 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.CIV.C.).
LENDERS NAME
LENDERS 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
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTION PROPERTY FOR INSPECTION P POSES.
IFJAVO'
PERMRTEE(P
A
SIGNA FPERMITTEE 7
ment Copy,YELLOWl-Finance Copy,PIN
PRESS
FIRMLY
APPLICATION D !j)PERMIT P/C
DATE NUMBER. #e��q
ISSUE TYPE OCC
-7/1 7
DATE
0 CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR p
SIDEISIDE STREET RW^
SIDE^
PROPOSED USE C�Ct•N•I
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
LLl Pat)olDeck
LL PooLSpa
u Re-Roof
Commercial
m
Valuation �•ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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I-
U
W
0
Z
m
a
Q
U
Z
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CONSTRUCTION
PLAN REVIEW J4.
Ia
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE•d�
SMIP•So
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: et-
PRE-ALT FEE:
2c--L may.- 16T3
TOTAL FEES 7 L+
COMMENTS
RECPT. N0. I ) PAID BY�WWDATION C_�n
AWN
LATIO
SEPT�TANK-'ZE-
JOBSITE
oL
ADDRESS
APN
LOT TRACT
OWNER
ADDRESS-
CITY L{P TEL.
APPLICANT TEL.
CONTRACTOR .!CAO
ADDRESS
CITY ZIP_fl TEL. !fjg
ARCF/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT.ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY 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-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
I71,AS OWNER OF THE 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 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,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT 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-
CENSE LAW DOES NOT APPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B.5 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
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COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED By SECTlON
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CONSTRUCTlON LENDING AGENCY
I HEREBY 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,CIV.C.).
LENDER'S NAME
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1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
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BUILDING PERMIT APPLICATION
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CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOARESAPERMTT TO CONSTRUCT.ALTER.IMPROVE,DEMOUSH.OR REPAIRANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES TIE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
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CENSE LAW(CHAPTER B (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
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A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5600).1:
DI.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGESAS 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 WHOOGES SUCH WORK HIMSELF OR HERSELF OR
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DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
P(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
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COMPENSATION.AS PROVIDED BY SECTlON 37000F THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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SHALL NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
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CODE. FORTFNA7H COMPLY WITH PAOVI S.y�i
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DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE INTEREST.AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY 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. 3087,CIV.C.).
LENDERS NAME
LENDERS 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
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(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI
CENSE LAW FOR THE FOLLOWING REASON (SEC. 70315 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
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CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
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TORS LICENSE LAW).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
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COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
�OF THE WORK FOR 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 WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'CO ENSATION INSURANCE CARRIER AND POLICY NUMBER ARE-
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SHALL NOT EMPLOY ANY PERSON IN ANY 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 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($1 M OW),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 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.)
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
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
ABOVE-MENTIONS PROPERTY FOR INSPECTION PURPOSES.
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RECPT N0. PAID BY ALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENRQD-File Copy,GREEN-Applicant's Copy
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
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APN LOT 2 7 TRACT Y 7853
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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 PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER. IMPROVE, DEMOLISH,OR REPAIR ANY 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-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I.AS OWNER OF THE 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 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. HOWEVER.THE BUILDING OR IMPROVEMENTS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
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^ 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-
CENSE LAW DOES NOT AP PLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I 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
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DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
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COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR 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 WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER D POLICY NUMBER ARE:
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(THIS SECTION NEEDNOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
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SHALL NOT EMPLOY ANY PERSON IN ANY 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 3700 OF THE LABOR
CODE.I SHALL FORTHW
COMPLY
WITH PR VISIONS.
AP
DATE LICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),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 HEREBYAFFIRM 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. CIV C).
LENDER'S 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
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PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE-
SMIP
ENERGY P/C
ENERGY PERMIT 0�
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
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
PRESS
FIRMLY
JOBSITE
d
ADDRESS
APN LOT TRACT
OWNER
ADDRESS tmw;?
CITY__:7/1 'al7it(ZIP TEL.
APPLICANT TEL.
CONTRACTOR F
ADDRESS s r
CITY ZIP TEL.
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 LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY 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.
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP.
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,AS OWNER OF THE 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 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. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT 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-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHOCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
0 I AM EXEMPT UNDER SEC. ! B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I 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
/AY LICENSE IS IN FULL FORCE AND EFFECT.
4
� 2
7174
LICENSE CLA
LIC. N0.
DATE L CONTRACTOR IF�fl
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR 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 WOR OR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' MPENSATfpN INSURANCE RRIER AN OLICY NUMBER ARE:
CARRIER
?Wz
POLICY NUMBER
(THIS SECTION NEW NOT BE COMPLETED OF THE PERMT IS FOR ONE MJFDFIED DOLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATIO .E OVISIONS F SECTlON 3700 OF THE LABOR
CODE,I ALL F RTHWITH COMPLY WIT HO P
NS,
;t
DATE: '� -APPLICANT.t
WARNING: FAILURE TO SECURE WORKERS COMPENSATI COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CI FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100.000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY 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,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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
ABOVE-MENTI9NED PROPERTY FOR INSPECTION PURPOSES.
P E NAME
SIGNA OF RMI E DATE
APPLICATION I
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41
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DATE
o- NUMBER
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#
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW
REAR
SIDE/SIDE STREET RW CI
SIDE
PROPOSED USE
N0. DWEL. r N0. N0.
UNITS/STORIES
BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL Pool/Spa
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Re-Roof
Z
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applibant's Copy
co'�
CITY OF DIAMOND BAR
INSPECTION RECORD
�iCTtON
DATE
INSPECTOR�
tNSPECTtON
DATE
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INSPECTOR