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Home My WebLink About17237 .-._." _-...,�\ I CITY OF D�OND BAR � = �' r' - �"'� DEPARTMENT OF CORRvIUNI'CY&DEVELOPME�'SERVI�CES _±�� N�� 21825 E.Copley �_a d�_ � �r (909)860-3195 Fax(909)861-3117 ` ��l" PRESS ' ""%��y' BUILDING PERMIT APPLICATION ��V , �_ FIRMLY o� JOBSITE A � APPLICATION � Gtii � NU B R��#/�=1� ADDRESS ��— �t`j��I�� C DATE � ISSUE TYPE OCC APN LOT TFjf1CT DATE CONST GROUP ¢ ( p OWNER a a' ZONING SETBACKS o ADDRESS �L Z CITY L• 't ZIP TEL. FRONT RW ❑ g APPLICANT TEL • SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR D SIDE C ADDRESS �� ^ PROPOSED USE < � CIN �' ZIP TEL. L o ARCH/ENG/ „ � A z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUIL�ER DECLARATION SFR/ADD/REM O � 1 HEREBV AFFIFiM UN�ER PENALTY OF PERJURY THpT I AM EXEMPT FROM THE CONTRACTORS LI� G2f0Q8/CBfPOfI W CENSELAWFORTHEFOLLO'NINGREASON�SEG.]031.SBUSMESSANDPROFESSIONSGODE:ANVCITYOP (n U COUNTVWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPFOVE,DEMOLISH,ORREPAIRANYSTRUG- w POSIO/DBCk wTURE,PRIOR TO ITS ISSUANCE,A�SO RE�UIRES THE APPUCANT FOR SUCH PERMITTO FILE A SIGNE� � STATEMENT THAT HE OR SVIE IS LICENSED PUflSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE lAW(CHAPTER 9(IX)MIAENpNG WITH SECTION�000)OF DNISION 3 OF THE BUSINE55 AND PflO� � Pwl/Spa O FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� U TION.ANYVIOLATIONOFSECTION7031.SBVANVAPPLICANTFORAPERMITSUBJECTSTHEAPP�ICANTTO Z Re-Root � ACIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLUflS(5500�.): � ❑I,�SOWNEROFTMEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COflllllBfCldl Z WILL DO THE WORN,AN�THE STRUGTURE IS NOT INTENDEO OR OFFEFED FOR SALE ISEC.'/044,BU51� J � NESS AND PROFESSIONS OJDE:THE CONTFAGTORS LICENSE LFW DOES NOT APPLV TO AN OWNER OF � \ PROPER7VWHOBUILDSORIMPROVESTHEFEON,ANDWHODOESSUGHWORKHIMSELFaRHERSELFOR m � THROUGHHISORHEROWNEMPLOYEES.PFOVIDEO-HATSUCHIMPROVEMENTSHRENOTINTEN�E�oR \ QOFFEREDFORSALEIF,HOWEVERTHEBUILDWGORIMPflOVEMENTIS50LDWITHINONEVEAROFCOMPLE Z TION,THE OWNER�BUILDEP.WILL HAVE THE BUiiDEN OF PROVING Th1AT HE OR SHE�ID NOT BUILD OR = IMPROVEFORTHEPURPOSEOFSALE). ❑I,AS OWNER Of THE PFOPERTV,AM E%CLUSNELV CONTRACTING W ITH LICENSE�CONTRACTORS QTO GONSTRUCT THE PRQIE:CT(SEC.1D44,BUSINE55 AN�PROFESSIONS COJE:THE CONTRACTORS LI� Vfllllfl�lOf1 ADJ.AREA W GENSE LAW DOES NOTFPPI_V TOAN OWNER OF A PROPERTV WHO BUILDS OR IMPROVES THEREON,AN� � WFIDCONTRACTSf04i5UCHPROJECTSWITHACANTRACTOR(5)IICENSEDPURSUANTTOTHECONTRAC- QUANTITY � DES RIPTION FEE '� TORS LICENSE LAW.). � fl I AM EXEMPT UN�Eq SEC. 6.8 P,c.FOR THIS REASON U � � � � � � � �ATE OWNER_'__ ~ ,.•; Z W w � LICENSED CONTRACTORS DECLAi7ATION -� Q w � I HEREBY AFFIRM UNDER PcNALTV OF PERJ�RV THAT IAM LIGENSE�UNDER PROVISIONS OF C!{qpT[R � d 9(COMMENCING WITH SEC�ION 7000)OF DIVISION 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z X MV LICENSE IS IN FULL F.^E�fJD EFFECT. m W / � � LICENSE CLASS � LIC.NO. � � J V DATE � C?� CDNTRACTOH �- d W � W�DRKERS'COMPENSATION DECLARATION J � ¢ � U � IHEREBYAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z Q 0 IHAVEANOWILLMAINTAINACERTIFICATEDFCONSENTTOSELF�INSl1REFORWORKERS' S QCAMPENSFTION,ASPROViDEDBVSECTION3]O40FTHELABORCODE.FORTHEPERFORMANCE w OF THE WORK FOF'.WHICH TMIS PERMIT IS ISSUED. � � W I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BV SECTION �� Q 3]OOOFTHE LABON CODE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMITIS ' ISSUED.MV WORNERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE� CONSTRUCTION � j cnaaiEa_ PLAN REVIEW �. ---- � POLICY NUMBER_ ELECTRIC � Z ¢ (RIISSECiqNNE¢iNOTBEOJMPI.FfEDOFTHEPERMfTISFORONEHUNDREDD�LLAR8�510�ORlESS). PLUMBING � w I GERTIFYTMAT INTHE PEFiFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL Z ('} SHALL NOT EMPL�V ANY PERSON IN ANY MANNER SOAS T00ECOM'e S JECT TOTHE �NSPECTION FEE Uj WORKER$' OM :NSATIONLFWSOFCALIF RNIA,ANDAGR'cETHATI OULODECOME -�- C C�� ? SUBJECT TH INORKERS'COMPENS P IONSOFSEeTI ]DOOFTHELABOR ISSUANCE ` i' CA E. OIarT� ITH COMPLV H P VISIONS. /' O �/ SMIP !��`� p DATE: w�APPLICANT: - w ENERGY P/C J WARNINGFAIL RETOSECUREWORKERS'COMPENSATIONCOVEflAGEISUNLAWFUL,ANDSHALLBE J � SU&IECTANEMPLOYERTDCRIMWALPENPL�IESHNDCMLFWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLL4RS(f700.000),IN ADDITION TO THE COST OF COMPENSAiION,DAMAGES AS PROVIDED FOR IN J SECTION s]oB oF TNE LAE��OR CODE.INTEREST,ANO ATTORNEV'S FEES. RETENTION FEE: _-..._ � w CONSTRUCTION LENDING AGENCV PRE-ALT FEE: ----- a O � I HEREBVAFFIRM UNDER PENALTY OF PEHJURY THATTHEftE IS AGONSTRUCTION LENDMG AGENCY n- FOR'NE PERFORMANCE�F THE WORK FOa WHICH 1MI5 PERMIT IS ISSUED(SEC.3a9�,CIV.C.). Z W S LENDER'S NAME � I- �EN�ER'SADDRESS_ ._ — wICERTIFYiHATIHAVEREADTHISAPPLIGHTIONANDSTATETHATTHEABOVEINfORMATIONISCORRECT TOTAL FEES ' � I pGPEE TO COMPLV WRN ALL CITV AND COUNTY ORDINPNGESAND STATE IAWS RELATING TO BUILDING � CONSTRl1CT10N,ANO HEi7EBV AUTHORIZE REPftESENTATNES UF THIS COUNTY TO ENTER UPON THE .� �� Z ABOVEME IONE PROPERTV FOR INS ECTION PURPOSES. COMMENTS --� � ��I G-vL l� J �, � m PERMITTEE E(P ➢YT� �� fj']� �� Q `/ �._ (�i/ C/J d/T/�� _.. — __ SIONATURE OF PCIIMITTEE � d- � RECPL NO.�,�'V U � __PAID 8Y VALIDATION 2 ~ WHITE—Department Copy,YELLOW—Finance Copy.PINK—Assessor Copy,GOLDENRO�File Copy,GR��`A plicanl'S Copy i��.� H? a �4,.'�4'�� IaPY�'��ry, �'�_ . . _ _ . . . .. � eS�-�`��e�i p.$ G �� NF�� . . � - , c � :.1.� . j( �J.��;1 J� __,- ` .f� �` _ µ� � . _ �: _ ,._.�.,�„ <_�.�.�. _�.�n,..a�,z: _ _ _ _ � : _ __ _ _ ; y _ ��' �� ai � � rv �� i�� p� . '.r �ra '�' � � ��`- .. .... . . . .. . ..... .... .. ... ... .... ..._ ._... .._ � �"�+.�,��m��°By�r�'��i�;��"s°'�5 a,. ' `` �' ��` � � �� r �� _ _ — _ � : n� � �� ri �a � � � � _ ��s �'t��` �;� , . �� „. : _ . xE . � ; � . � _ �� , . , �_� � �.m .� _ _ �_ � �- � _ �� JOBSITE ADDRESS 2 3a APN LOT TF,1CT OWNER Gt a. .( ADDRESS CITY t•ZIP TEL. APPLICANT TEL CONTRACTOR 0 ADDRESS ?4 CITY&'ZIP TEL L'C I 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 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($5001.): ^ 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-BUILDEP 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. &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 SEC NON 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FCECO EFFECT. LICENSE CLASS LIC. NO DATE to! f CONTRACTOR 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 FOF'.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 AND POLICY NUMBER ARE: CARRIER POLICY NUMBER_ (THIS SECTION NEED NOT BE COMPLETED 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 EMPL IV ANY PERSON IN ANV MANNER SO AS TO BECOME S JECT TO THE WORKERS'OM :NSATION LAWS OF CALIF RNIA,AND AGREE THAT I OULD BECOME SUBJECT TH WORKERS'COMPENS P IONS OF SEQTI 700 OE THE LABOR CO E.ORT ITH COMPLY H P VISIONS. DATE:APPLICANT: WARNING: FAIL RE 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 I AGREE TO COMPLY WITFI ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ECTION PURPOSES. ABOVE ME IONS PROPERTY FOR INS / P ��I G�vL C/ 4 PERMITTEE E(P'J- SIGNATURE OF PERMITTEE D rri CD Ir 0 LL w 0 DO LL 0 d X W 0 U w C13 0 W W (.D 0 w J J 2 CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive �b 1 (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY APPLICATION PERMIT P/Co DATE NUMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ - .44 2 4 PROPOSED USE 2 N0. DWEL, N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR P SF ADJ.AREA/VALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck LL Pool/Spa Z Re-Root Commercial Valuation ADJ.AREA QUANTITY DES RIPTION FEE Q W J LU 0 Z -J a Z 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE C ISSUANCE I I SMIP o i 1 0 ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES So t)I •� COMMENTSf( oi " RECPT. N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GR A plicant's Copy