HomeMy WebLinkAbout10572CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
;.W 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
t."t BUILDING PERMIT APPLICATION
ADDRIESS !� i V l�l-� E 7 • .Z �Z't _�
APN LOT TRACT
OWNER kLf ''
ADDRESS Lt. -Il /V
CITY 16 GL' ZIP t TEL.
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APPLICANT " P f} .� Se`i. ° t!Z, ? , TEL.
CONTRACTOR r�,A;1:T�0-'rl[.''ye L / d S7 J k % /err�..
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DESIGNER
ADDRESS
CITY ZIP TEL. _
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH REOUIRESAPERMIT TOCONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC
TURF, 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 S (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE 15 EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THEAPPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (8600).):
D 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.-
NESSAND 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 HERSELFOR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT 19 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).
113 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING, WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFES510NS 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.).
❑ IAM EXEMPT UNDER SEC. __. B. 6 P.C. FOR THIS REASON
DATE _ _ - OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM 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 D EFFECT. /o `. rn ll
LICENSE CLAS LIC. NO. ,_ r -
('L9 C 7 `JS Yo—
DATE CONTRACTOR_rT'^'
Ct \,3 U
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' OOMPENSATION 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 _ yV wCer-
POLICY NUMBER
(rHSSECnONNE®NOTECO MPLETEDOFTFEPERMIrisfORONEHIAVDREDD0UAR5(SI00)ORLESS).
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
WOnKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LAEOR
CODE ISH FO�I THWITH COMPLY WI7.S1{OSE g}OWSIONS. 9 i
DATE: APPLICANT: .Ij�;;. `- •
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (8100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3705 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3097, CIV. C.).
LENDER'S NAME ,. .—
LENDER'SADDRESS
i CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TH E 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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PEijVI E NAME (PRI N{ T`) Tt L
SIGNA I gF, DA E
PRESS
FIRMLY
DATE CATION f NUMBER kPERM 7/C� �t t%�
ISSUE % y� TYPE OCC
j
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW LJ _
REAR Cl
SIDE/SIDE STREET RW EJ
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SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
C/3
Gerage/Carport
W
Patio/Deck L� )
LL.
POOVSpa
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Re -Root
Commercial
Valuation -(� ..- _ ADJI.AREA
QUANTITY DESCRIPTION FEE
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ELECTRIC •__
PLUMBING
MECHANICAL
INSPECTION FEE _._.
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ISSUANCE V •
SMTP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
1-1-97
TOTAL FEES
COMMENTS_.
RECPT NO.PAID BY -CZVALIDATION nA—
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
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