HomeMy WebLinkAbout14947 (27)CITY OF DIAMOND BAR �/
J - ' DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
C
21660E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION _.r
JOBSITE
ADD ESS_ Dl t 5� D I JT AC'N 1) 136P- P64D
APN LOT TRACT
OWNER L �.l
ADDRESS E If)-,
CITYj!!�,DWhA-1 ZI ,0TEL
APPLICANT TEL. - :72S!7
CONTRACTOR ��
ADDRESS Z i Z L •
CITY ZIP" TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LIS
CENSELAW FORTHE FOLLOWNO REASON (SEC.7041.6 SUSNESSAND PROFESSONS CODE:ANYCTTYCR
COUNTYVIHICH REOURESAPERMrTTO CONSTRIICT.ALTFR. IMPROVE,DE000SH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
CENSE LAW (CHAPTER 0 MMMENCINO WITH SECTION 7000) OF DIVISION S OF THE BJSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE 15 EXEMPT THEREFROM AND THE BASIS FORTHE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7041.6 BYANYAPPUCAHT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF HOT MORE THAI FIVE HUNDRED DOLLARS pSIX).7
O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT MENDED OR OFFERED FOR SALE (SEC. 7041, SUS4
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 HE RS ELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE F,HOWEVER.THE BULDING OR MPROVEMENTIS SOLD WITHIN ONE YEAR OFCOMPLE-
TON. THE OWNER-SLXIDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
D L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING VMH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70". BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY 70 AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
V040VRCONTRACTS FOR SUCH PROJECTS WITH A CO TRACTORS) LICENSED PURSUANT TO THE CONTRAC.
TORS LICENSE LAW.).
O I AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFF3W UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE, AND
W LICENSE IS N FTKL FORCE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRAC
WORKERS'COMPENSATION DECLA A
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I HAVE AND WILL MANTAN ACERTIRCATE OF CONSENT TO SELFaNSURE FOR WORKrLFS
COMPENSATION, AS PROVOED BY SECTION 4700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMR IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
5700 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�vj b
POLICY NUMBER Z..
(OLS SCCnM WM WJT BE OMVLETMCFTHEPERMTIS RJR ONE HMEALDMLXIS OIOO)OR LESSI
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T HIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PE4ANYMER 50 AS TO BECOME SUBJECT TO THE
WORXERS'COMPFNSATXJN NIA,ANDACR T iIFISHOULDBECOME
SUBJECT TO THE WORKERSPROVISIONS0 S;ON 47000E THE LABOR
COOE.1 ALLF RTi/WiTH5E PROVISIONDATE: APDWARNING: FAILURE TO SECURE WtlATION C�VERAC IS UALIIWFUIS AND SHALL B[
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO 011E HUNDRED THOUSAND
DOLLARS (4100,000), IN ADDITION 70 THE COST OF COMPENSATION, DAMAGE! AS PROVIDED FOR IN
SECTION $703 OFTHE LABOR CODE, INTEREST AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HERESY AFRW UNDER PENALTY OF PERUUIW THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3037. CN. O).
I
LENDER'SNAME
LENDEFSADORESS
I CERTIFY THAT I HAVE READ THIS APPLKATON AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULDING
CONSTRUCTION,ANO HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED N10PERTY FOR INSPECTION PURPOSES.
L .
PETWIRTEE NA :(PRINT)
8 REO TTE DAI E
PRESS
FIRMLY
APPLICATION
L. PERMITLy P/C C6
DATE
NUMBER !
#yCJ '�/
Q2
ISSUE
TYPE
OCC
'DATE
CONST.
GROUP.
ZONING SETBACKS
FRONT
RW
❑
REAR
I
❑
SIOE/SIDE
STREET RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL.
NO.
NO,
UNITS
STORIES
BEDROOMS
DESCRIPTION
SO. FT: - FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
'
U)
Gamote/Carport
'
WPatio/Dock
U-
PooVSpa
Z
Re -Root
'
Commerc
1
Valuation
ADJ.AREA
QUANTITY
DESCRIPTION
FEE
J
Q
4
3
Q
G -
W
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2
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CONSTRUCTION
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ELECTRIC
PLUMBING
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tM�ECHANICAL
INSPECTION FEE
ISSUANCE
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ENERGY P/C
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ENERGY PERMIT
RETENTION FEE:A^j=
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TOTAL FEES
~
COMMENTS
I
RECPT. NO.
PAID BY
VALIDATION
WHITE—Department Copy. YELLOW—Finance Copy, PINK—ASSOIsOrCOPY, LiU(ntNHCILr-+Ile L;CM uHu:r4--Applcanrs copy