HomeMy WebLinkAbout16622 �,,.� CITY OF DIAMQND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��/
2156t?E.Copley Drive Suite 190
(90'9)86(�3195 Faz(409)$61-311? PRESS
'ry^''� BULLt1ING PERMTI'APPLICATION FIRMLY
� JOBSITE � ` „ qpPLICATION /_��(`�) PERMIT � r� � C
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p OWNER �-_—_
� ADDRESS ��I�� Jf?t�LR,+u4lr k�1J • ZONING SETBACKS
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ADDRESS
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� ARCWENG/
DESIGNER,
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vs DESCR�PTIdN SQ.FT. FACTOR PSF ADJ.AREANALUATION
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TURE,PRN7R TO ITS ISSUANCE,AL50 REOUIRES THE MPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
.n� STATEMENT THAT HE 4R SNE tS�/CENSED PVRSUR7V7 i4 TFiE PAQVI$IONS OF THE CaNTRACTORS U-
X� CENSE tAW(CHAP7Eq Y(CXIMMENCINq WIIH SECTION 7qD6)OF DIVISI4N 3 QF THE 9USINESSANO PRO- LL' POOI/Spa
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YAt.I OQ THE WORK.M7p rHE 5TRUCTtIRE IS FJOT INTENDED pR OFFERED FOR SALE(SEC.70M,BUSb �
� NES5 AND pROFESS10N3 CODE;TME CANTRACTOR5 LICENSE U1W DOES N6T APPIY TO AN OWNER Of =
PROP£RfY YfF108UkDS 4P IMPp�VES 7HEfiEON.MDwF10 DDES SUCM irWpK HiF.k'iEIF OR HERSELF�R
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QFFEiiED FOR SN.E.IF,FHSWEVEI'i,TiE BUILDING OR IMPfiOVEMENT IS SOLD WITHIN ONE YEAR Of CAMPLE•
TqN,Tt�fYNNER�BUkDEA Y!i{y.Hl1VE 7HE BUF�EN OF PRflYMIG THAT HE OR 5NF 07D NOT BUItD OR
IMPiqVE F4R iNE PUqPOSE OF SALE�.
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� Wl1000NTfiACT5FOR5UCMPR0.IECTSWITHACONTMC?OR{SjUCENSEDPUti3UAMTOTHECONTflAG QUANTiTY DESCRIPTION FEE
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171 AM EXEMPT UNDER SEC. S.d PC.FOfl THIS FEASON Q � '`~� �,
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� �ICENSED CONTRACT6RS OEC�ARATION W .-�" � �
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ac 1 NEREBYAFFIRM IINDER PENhTY OF FEFUURV THAT i AM UCENGED UNOER PROYISIQNS Of CHAPTER � 'J /y,
� Y(COMMENCINt3 WITH SECTiON 706D)OF DIVISiON 3 OFTHE BUSiNESS AND PROf:SS�ONS f.ODE,AND Z f� y {,,,/
7{ MY LICENSE IS IN FULL FORCE AND EFFECT
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G1 __I MI1VE AN�WILL MAINTAIN A CERTIFICATE OF CANSENT TO SE4F-IUSUpE FbR WORKEHS' = 7 • �
Q CBMPENSATION.AS PROYI6EQ BY SECTION 31oa OF THE IAeOR COOE,FOR 7NE PEPfoRMANCE U � �✓ 'ti--��
OF THE WnRN FOF 4VHICH THIS PERMIT IS 195UEp. W
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� ,,,,J,I HAYE ANU W�LL MNNr�11N WOKiKERS'COMFENSATION IN5UqANCE.A3 REO111RED BV SECTION —����
3)00 OF!HE UB4Fi CODE,fOfl THE PERFORMANCE OF THE W4RK Ff}0.WHICH TNIS PEAMIT IS
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� SU&tECT TGY7HE WbRICERS'C(1MP£N5ATION PROViSpN%OF SEGTION S]00 UF THc LFBOR i �....�
CQDE,I SHALL F'OHTHWI7H COMPLY WITH iH05 ROVISIONS. ISSUANGE
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� ENEFiGY P1C _
WAflh'M7�:FAdAtRE TO SECURE WDAKERS'WMPRI3ATION CAVERAGE IS VNLAWFUi.,ANU SHALL BE
� SUBJECTAN FNPLOYER TO CRIMINAL pENALTIES ANp CIVIL FWES UP TO ONE HUNDRED THOUSANb ENERGY PERMl7
DClURS{ft00.Wv},M!ADDiT7flH TO TNE COST aF COMPENSAiION,DAMAGES AS AROV@£t7 FOR IN
aSECTIClN31o90FTHELA60RCODE,INTERE5T,ANDATTORNEY'SFEES. RETENTIONFEE: „ � __
aCONSTRUCTIOFI l.ERtpItJG AGENCY PRE•ALT FEE: �_,
� i HEREBYAFKINA{UNpER PENAITY 6r PERJURY THAT THERE 15 ACOMSTftUGTiQN IENDiNG AGEF�Y
FOR 7NF_PERFORAiANCE 9F THE WOfiK F6fl NR IICH 7HI5 PERMIT IS i55UE0�SEC.3p87.CIV.C.).
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F— I.FNDEAS ADPRESS_„_ _"_' ..... .
� 1 CERTIFY TNA714AYE AEkCI THiS APVLICATIONAN�STATE THAT TtiE A&>VE INfORMATIQti IS CORNECT. 1�TAL FEES �
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� I AGflEf TO C[7AiG�V WITH A1L CiIY AND COUNTY ORb�NANCES AND STATE U1W5 RELATING 70 BUILD�NG �'"�
'M (;ONSTRIICTION,ANDMEREBYAUTHOR2GREPRESENTATIVE50FTHISCWNTYTOENTERUPONThIE
� APQVEMENTiONEQ PROAE�TY FOft i,'iSPECTKK4 PUftP45E5. COMMEM1ITS
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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
P ktyl
PRESS
FIRMLY
JOBSITE
ADDRESS 8 U�?%Z Y5 T
APN LOT�TRACT
OWNER
ADDRESS/�ORXR,4' i IJ
CIT Q�LLYfL�X s�ZIP�Z'3 TELYf S>YD v
APPLICANT TEL.
CONTRACTOR,ANC,
ADDRESS
CITY ZIP5/?/0 TEL 2762
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 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 BY ANY 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 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 OFA 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
R(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
7
LICENSE CLASS L_J_LIC. N0.t[�99
DATE-6--J I CONTRACTOR'/JOGiI/4
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 WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIE D POLICY NUMBER ARE:
-��--'I i
/
POLICY NUMBER 2I�,p
(TORS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE FRNCRED 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 THOS ROVISIONS.
V
_APPLICANT G�°'/"
DATE: 4
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECTAN 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. 3087,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
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERMITTEE E(PRINT)
SI ATURE OF PERMI E DATE
APPLICATION(�_ PERMIT
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DATE V 1 NUMBER/
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR ^
SIDE/SIDE STREET RW^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
CI) Garage/Carport
W Patio/Deck
LL
Pool/Spa
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Re-Roof
Z
0 Commercial
D
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 oil
VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy. GOLDENROD-File Copy,GREEN-Applicant's Copy