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Home My WebLink About15000 (30)CITY OF DIAMOND BAR f DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE` , ADDRESS+ q It APN LO T ACT _ ADDRESS9 R h CITY �`IA !✓02 f I ZIP q/ /� TELS ✓Z� APPLICANT �.aL/_ /soh- A/6byF.a'i TELgy_1- CONTRACTQF�I ADDRESS �LLL662Z P/Lp� M/fir �P +4% b� CITY e,4DLf'ZIP TEL. % ARCH/ENG/ W-11777 DESIGNERq.C_ U_ SQ iy2e ADDRESS/��75' &e2&4e/ .1 f2!!'1.Ci/!/4W,-Vi CITY _ 2RVTAO' ZIP 9 d/�q TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH REOUIRESA PERMITTO CONSTRUCTALTER, 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 $ (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 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML 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 WORK . AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUST 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 OWNEMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR 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). 01, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING 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.). C I AM EXEMPT UNDER SEC. B.8 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 DIVISION 3OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULL FORCEAND EFFECT. LICENSE CLASS UC. NO. S 09 f DATE CONTRACTOR. Q& P!�- WORKERS' COMPENSATION DECLARATION [A/�! ^r� I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DE RATIONS: _I HAVE AND WILL MAINTAIN A CERTIFICATE OF OONSENTTO SELF -IN REFORWORKERS' COMPENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR COD FOR THE PERFORMANeE— OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _ I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REOUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERSCOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUN6ER (rHIS SECfUV NEEDNOT BECOMPLErEDOFTNE PEFW IS FORONE HUNDRED DOLIARS(SIOO)OR I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, SHALLNOT EMPLOYANY PERSON IN ANY MANNER SOAS TO RECOME 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, IISHALL LFFORTHWITH COMPLY WITH THO PROVIS NS. DATE: X'2441:70 APPLICANT: _ WARNING: FAILURE TO SECURE WORKERS'eN COVERAGE IS UNLAWFUL, AND SHALLBE SUBJECT AN EMPLOYER TO CRIMINAL PEN LFINES UP TOONE HUNDRED THOUSAND DOLLARS ($ 700,000), IN ADDITION 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 C.). LENDER'S NAME LENDER'SAODRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY ANO 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. U% -� PERMITTEE N SIG FPER0171EE DATE e PRESS FIRMLY APPLICATIO -- PERMIT Li f� (i� P/C DATE _Z ` _NUMBER11- - # ISSUE j Z_ TYPE OCC L DATE_ ��T� CONST. GROUP ,L ZONING SETBACKS FRONT RW I REAR _ SIDE/SIDE STREET RV/ Ll SIDE p� PROPOSED USE NO. DWEL. NO. NO. UNITS ?�G/��%� STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport WPatio/Dock LL POOVSP3 Z Re -Roof Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE 5.-11614(01 G ii7 U W J W Z M _ Z ONSJR C N _ J` -I E EW _ r TRIC v PLU ING MECH I C 10 EE M^' ISSUAN SMIP - ENERGY P/C G781 ENERGY PERMIT `x'43: RETENTION FEE: .3xx�T,�T t-x✓:+.fie" .r ' s;e.��`? PRE -ALT FEE: Vii''j �Aa TOTAL FEES 0 %--1 COMMENTS _ RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW--Finanoe Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy