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Home My WebLink About15117 (8)0 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 DEPARTi>ZENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Staite 190 (909) 860-3195 Fax (909) 851-3117 — BUILDING PERMIT APPLICA. JOBSITE j OI Z — I—CL 30 — ADDRESS APN LOT TRACT OWNER C' E—..'C —»0 G -4("l L= -n ZIP ' — 17-0— TEL. CITY ; APPLICANT, —C"oY..c.3 Ed2_,la TEL.cI" ' /y CONTRACTOR -T " "" " L- "z_ A ADDR SS"" " V" " -' CITY ")- ZIP iTd TELC1"f ------ ARCH/ENG/ -----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: ANV CITY OR CWNTY WHK71 REWIRE;I A PERMR 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 IAW (CHAPTER D (IXNAMENCING WITH SECTION 7000) OF DIVISK)N 3 OF THE BUSINESS AND PRO- FESSpNSCODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VpI.ATpN OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70 ACML PENALTY OF NOT IAORE THAN FNE HUNDRED DOLLARS (5500).): - I, AS OWNER OFTHIE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 704x, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PFOPERTY WHO BU5D5 4R IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THfpUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERW FOR SALE IF, HCIWEVER 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). 0 I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WFTH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7011. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, PND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS UCENSE LAW.). ^ I AM EXEMPT UNCIER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDEFI PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTON 7000) OF DNISION 3 OF THE BUSINESS AND PROFESSKNS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. t""/"p" "? " " "" LIC. NO. ".J" " V t S LICENSE C L AS QD R— CONTRACTO DATE=— WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEM TOSELF-INSURE FOR WORKERS' COMPENSATKI, AS PROVIDED BY SECTION 37000E 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 BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WGRKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (G5S SECTION NE®NDT BE CXIAPLETmOF TFE PEFC.1fF IS FOR ONE RUPARED DCLIARS (5100) OR LE55) I CERTIFY THAI' IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT LS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COINPENSATKNJ LAWS OF CALIFORNIO. AND AGREE THAT IF 1 SHOULD BECOME — SUBJECT TO THE WORKERS'COMPENSATION PROVIS SOF SECT N37000F THE LABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PR ISION D ,Yv- 1 PPLICANT: DATE 1 I I WARNING: FAILURE TO SECURE WORKERS' COMPENS ION COVERAGE IS UNLAWFUL. AND SHALL BE 1 SUBJECT AN EMPLOYE'.R TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLURS (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM LINO ER 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.). i LENDER'S NAME LENDER'S ADDRESS — I CERTIFY THAT I HAVE READ THIS APPLICATKN! AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT. I AGREE TO COMPLY WITH ALL CFTV AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING s CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTKN/ED PROPERTY FORINSPECTKNJ PURPOSES. — PERMITTEE NAME (PRI /!/--0 — SpNATURE OF P MIITTEE DATE ION PRESS FIRMLY WHITE --Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy CITY OF DIAMOND BAR I—c'.MICTI",TION RECORD "" G""1... F"GTIC"N —