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Home My WebLink About151170 CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195Fax(909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY JOSSITE_7)0 ADDRESSjUt b4= -L — L - APN — LOT TRACT OWNER (QPMA 1 14 ADDRESS CITY 1'�) ZIP 9176 TEL. APPLICANT _C:_C>7_cGJ TEL. -CID 09"YA i CONTRACTOR ADDRF,SS -:6) CITY Z, r* ZIP EIII 1'6-j TEL.0 ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U. CENSE LAW FOR THE FOLLOWING REASON (SEC. 7MI-SOUSINESSANDPROFESSIONS CODE: ANYCITYOP COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER IMPROVE, DEMOLISH, OR REPAIR ANY STROC. TUBE- PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATFUM THAT HE ORSHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI CE14SE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS OODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP, TON. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): 01, AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL Do THE WOW AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSF NESS AND PROFESSIONS OWE, THE CONTRACTORS UCENSF LAW DOES NOT AP FLY TO AN OWNER OF PROPERTY WHO BUILDS OR "PROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS On HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE- IF. HOWEVER, THE BUILDING OR iMPROVEMENTIS SOLD WITHIN ONE YEAR OFOOMPLE- TIQN, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 01. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT THE PROJECT (SEC. 70", BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTSFORSUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONI TONS LICENSE LAW). 0 IAM EXEMPT UNDER SEC. R & 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 DNISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS j?, 1,4 1 C_ LIC. NO DATE 2—'200 0 CONTRACTOR tz— h 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 PO' ICY NUMBER ARE: CARRIER POLICY NUMBER (IMISSECTION NEEDNDTBE OMUTEDOF THE PERMIT 6 RORONEHUNOREDDOLLARS ($100)ORLrsS). I CERTIFY THAI' IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALLINOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAW. OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJ EC I r TO THE WORKERS'COMPEN SATION P ROVI S SOPSrCTI N370GOPTHE LABOR I CODE, I SMALL) MALL FORTHWITH COMPLY WTH THOSE P SION DATE Z ' Loo, APPLICANT: WARNING: FAILURE TO SECURE WOFIKERS'COMPENS ION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SI00,00D), IN ADDIHON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION 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. 0.1. TENDER'S NAME LENDER'S ADDRESS 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-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMITIREENAME fpill 11 / ll14 j SIGNATURE OF7RMITTFIE DATE APPLICATIO PERMIT 5*/ 1-7 P/c DATE/ NUMBEF1f' ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW 0 REAR FI SIDE/SIDE STREET — RW Ej 1:1 SIDE PROPOSEDUSE,. No. DWEL. NO. NO. UNITS STORIES — BEDROOMS DESCRIPTION SC. FT. FACTOR PSF ADJ. AREA/VALUATION SFFVADDfREM ca 0 Garage/Carport LU Patio/Dock LL PooVSpa ZRe -Roof Commercial Valuation ADJARFA QUANTITY DESCRIPTION FEE le r5,' 0 r cc C)F_ LL 0 z 1 _/ U A -011w - C , V d CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING C MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY PIC ENERGY PERMIT RETENTION FEE: PRE F TOTAL FEES COMM 4 0 s� Aw REOPT. NO. PAID BY VALIDATION WHITE --Department Copy, YELLOW --Finance Copy, PINK—Assessor Copy, tiOLDENR6D,-Fjle Copy, GREEN—Applicant's Copy 14 -A K S