HomeMy WebLinkAbout11861 --�'�`,^-- -- CITY OF DIAMOND BAR ��'"`
DEPARTMENT OF COMM:UNiTY 8c TlEVELQPMENT SERVICES
M.,,,w����' 21825 E.Copley Drive
(909)$60-3195 Faac(909)8613117 PRESS
�'*"' BUILDING FERMi.T APPLICATiON FiRMI.Y
�� JOSSITE ^-� (� APPCtCATt4N _ �_ t��� PERMIT .� � P/C
ADDRESS � �� / L����L ��C��rab �rL' DATE �NUMBEA_ #
� ISSUE TYPE OCC
APN I_OT TRACT_ DATE CQNST. GROUP
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� dWNER-BUILDER DECLARATION SFWADp/REM
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�MEREBY AFFli�.i ttNUER PENALTY 4F PERNRY iHAT F ud ExEtriWT GR06i iHE CON'iRACTt1R5 li- Ga19ge/C6fpOlt
W CENSEI,AWFORTHEFOLI.G+WIN6REA£iQN(SEC.7o37.5BUSINESSANOPROFES5lONSCA�E:ANYCITYOp (n
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7URE FRIOq TD ITS ISSUANCE,J150 AEOUIRES hiE APPLICANT FOR SUCH PERMIT TO FILE A SiGNED
�W STATEIAENT TNAT HE OR SHE IS IJCENSED PURSUANT TO THE PflOVISIONS 4F 7HE CONTRACTORS LF W
CENSE UW{CHAPtER V{Ct?MMENClNf3 N7Ttv SECTIQN 7�)OF O�YISIQN 30F TME BUSINESS ANp PfiO. � P66USp8
FESSqN5IXX7EjORTHATHEOflSHEiSE%EMPTTHEREFPo6MANpTHE0h515FOqTHEALLEGEDE%EMP. �
TION.ANVVN7LATIONOFSEGTION7031.SBYANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-Roof
� A C1Vft.PENAlTY Of P1QT AX�ftE TNMI FiYE NUN6RE0 DOlU4R5 iiS03}.}:
� O�,ASOWNENOF7MEPpOpERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSpLECOMPENSAiION, COflIfnBlaiel
WILL W THE WORK,AND 711E SiRUCTURE IS N�T iNTENpED oR OFFERED FOA SAI.E{SE0.7oa4,BUSb �
� NESS M!D PflqFE$SlONS Gy3DE:THE CONTRACT6RS LICENSE tkW WES NOT APGIV T6 AN OWNER OF �
PROPENTY WHO BUILOS OR IMPqpVES THEREON,AND VAi4 DOES SUCH WOFiK HIMSELF OR HER5ELF OR
[[ THRdJ(iH NIS OR MEA OWN EMPl.OYEES,PROYIDED THAT SUCH IMPROYEMENTS AAE N4T NiTENDEQ 4R m
�,�,7 OFFEAEDFORSAi.Efi,NOWEVEH,THE94NlDINpORiMFROVEMENTI550LOWi7HINONEVEAROFCAMPLE
� TION,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVWp 7HAT HE 4N SHE DID NOT&11LD OFl
� IMPftl7VE FOfl TNE pUfiPOSE OF$AlE}.
W ❑I,ASONMEHOFTHEPROPER7V,AME%CLUSNELYCANTRACTINqWfTHLICENSEDCQNTRqCTOR5
(� TO CONSTRUCT TiE PROJECT(SEC.7QN,BUSINE5$ANO PROFESSIONS COOE�THE CAM'RAC70R5 U- V81U8U0(1 ADJ.AREA
LL1 GENSEtAWO0E5NOTAPPtYTOANQWNEROFAPROPERTYWH68t3tlOSORiMPFCOVESTHEREQN,FNp
� WHOGON7qACTSF4RSUCF'PRWECT5WITNACONTRACTOR(S)LICENSEOPURSUANTTOTNECONTRAG QUANTITY DESCRIPTION FEE
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� ❑I AM EXEMPT UNDSR SEC. 9,6 P.0 FOR THIS HEASON Q
� U
W �
pATE OWNER �
� W
rs[ I.IC:ENSED CONTRACTORS DECLARA710N W
CL I HEREBY AFFIRM UNDER PEIVA�N OF PFRIl1RV THAT I AM LICENSED UNbER PROVISI4NS OF CHAPTER � �..�-K ,�,*-,(,,,,, �, '� �
� 9{COMMENCINd WITH SECTIDtd 7W0}6F flIVIS10N 3 OF TFIE BUSINESS AND PAOFESSIONS CADE,RNO Z
�{ MY t7CENSE iS M FUI.L FpRCE AND EFFECT.
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� WQRKERS'GOMPENSATION DECLRRATION 4
� IHEREBYAFFIpMUNDERPENALTYOFpER1UflYONEOF7HEFOlIqWINqOEQARATI4NS: z
d _IHAYEANOWIILMAItJ7AINACEfifIFICATEOFCONSENTT45ELFINSUREFOPWORKERS' _
Q COMPENSATIOM,AS PFiOVIDEO BY SECTION 37ooOF THELABOR CODE,FOA 7HE PEftFOPMANC'c �U
OF THE WbRK FOR W HICN TH�S pEAMiT IS i$SVE6. �
�
W i tfAVE MID WILL MAlNTAM7 WOftNEFiS'COMPENSATKK�'INSUPANGE,AS REIX11RE6 8Y SECT�a'
�QG, � 3�0o OF THE IJBOR c%X7E,FOq THE PERFORMANC6 OF iNE WORK FOq WHICH THIS PERMIT IS
ISSUED.MY WORKERS'CpMPEN5A710N INSURANCE�CaAA�q1ER�AnND POI.IGY NUMBERARE: GONSTRUGTION
yCARHIER_��_.rp�'��� / �""�'� PLAN REVIEW
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W
�' t CERTIFY THAT IN TFI[PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANIC.RL
� SHALL Fm7 EMPlOY ANY PfRSON tN ANY hiANNER SO AS TO eECOME SVBJECT TO iNE �
(/) WORKERS'COMPENSATION LAW9 OF CALIF6pNlA AND AOREE THAT IF I SHOl1lD BECOME INSPECTION FEE ,,,,,,,
SU&1ECT707HE WOIiKEF4S'COMPENSATbM PROVISI�NS OF SECTION�T4a pf TNE IABOft �"'�_�/
� CWE,ISNALLFORTHWIiHCOMPLYWi TH evrwvisioNs. �SSUANCE ��f ,� ��r
a -' -z. -� "�-�--.
p DATE:� � �3 APPIlGANT: SMIP
� WARNING:FMI.URETOSECUPEWbRKERS'COMPENSATI�NCOVERAGEISUNlA1MFUl,ANDSWLLIBE ENERGYP/C
� 5UBJECTANEMPL6YERTbCR�67MAlVENALTiESANC1CiViLFiNESUPTOONEHUNDNEpTFKK1SANp [NEFIGYPERMIT
DOlURS(f1dS,oaO),IN A�pITION TO THE COST OF C4MPENSATqN.DAMAGES AS PflOVIDED FOR IN (
� SEGTION 3Tp80FTHG lAB6R COOE.INTEREST,ANDATT4RNEY'S FEES. RETENT�QN FEE: 1 �•O�j,
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _
� I HEREBV AFFIRA/UNDER PEN�4LTY OF pERJUpV iHATTHERE IS A CpNSTRUCTION LENpWG AGENCY
fOR THE PEF3FORMANCE OF THE WORK foR WklCH TFits PERMiT IS ISSUED(SEC.3991.GIY.G.}. ""'—""
�
� 4ENDER'9NM16
1-- LENDER'SADORE55
� TOTAL FEES 4 �
� I GERTIFY THAT I HAVE REAO THIS AVPLICATION AND S7ATE TMATTHE ABOYE INFORMA710N 15 CARpECi /�f �
W 1AGREE70C4MPLY417THAlLdTrANDCWMYOf�SWANCE5AN65TAiEUW5REUTWtiTbBUll.piNG
� CONSTPUCTiON,ANDµEREBVAUTIiOR2EREPPESENTATIVE50FTHt5GWNTYTOENiERUPONiNE
� ABOVE•MENTIGNED PROPERP/fOR INSPECTIGN PURPOSES,
� (.��� � �� COMMENTS
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= RECPT.NQ. PAI6 BY � VALIpAT�N
~ WHI7E—pepaAment Copy,YELLOW—Finenee Copy,PINK—Assessor Copy, I.DENROD--File Copy.GREEN—Applic.eM's Copy
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DIAMOND BAR i
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ADDRESS I Y-7-1 6y U,7(_I.tG r-rs'L Pi
CITY
.ZIP y 1765TEL.-96/-
APPLICANT TEL.
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CONTRACTOR
ADDRESS 1' itC -
CITY,Z ZIP !II164TEL.f1 �7 LAY)
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 REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIRANYSTRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SIZE 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).):
^ 1,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 NOTAPPLY 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 PEI4ALTY 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 CLASS L LIC. N0. 7�E S
DATE I-I (,'- �)CONTRACTOR-4't_'-
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 CARRIER AND POLICY NUMBER ARE
2e1tIG� IC
CARRIER fjr:
POLICY NUMBER K41
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMT IS PORCINE FAXDRED DOLLARS(1100)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 WIT THH EPROVISIONS,
I
AT
VWt"��^'�
D
E:
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(5100,000),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. 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.
PERMITTEE TAME(PRINT)
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SIGNATURE OF PERMITT E DATE
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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
APPLICATION PERMIT P/C
DATE 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.AREANALUATION
SFR/ADD/REM
Garage/Carport
W Patio/Deck
LL PooVSpa
Z Re-Roof
0 Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
U
I-
U
W
J
W
Z I
vv--,X 4,17-7L,C_t.
a
Z
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE y
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
CAT
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PIN