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Home My WebLink About15052 (17)C- - (b CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 w (909)860-3195 Fax(909)861-3117 BUILDING PRRNUT APPLICATION JOBSITE iJ ADDRESS f I / :..: T. a: r, APN LOT TRACT OWNER 1%1 $4 ADDRESS S`rz ,.. .c. 7s 4. 4j/_A CITY _ ZIP _ TEL. APPLICANT /• t TEL.Q..r_��H�''t.:o CONTRACTORS•° t•• , 4 tai • ...A....; d �� R . ADDRESSP_gr CITY Ar6parG a G. ZIP J10 Cif TEL. -1% '4� �C- ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC- TURE, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE UW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- 710N. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJEC TS THE APPLCANT TO ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SOW).): ❑ 1. AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGESAS THEIR SOL E COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7069, BUSI. NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELF OH HERSELF OH THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN UNE YEAR OF COMPIE- 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 WITH LICENSED CONTRACTORS To CONSTRUCT THE. PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CON TRAC. TORS LICENSE LAW.). ❑ I AM EXEMPT UNDER SEC. __ B. A P.0 FOR THIS REASON DATE LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT AM UCENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CGDE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. C-7 . v L .-,10 L _11 .-, LICENSE CLASS LIC. NO. DATE _ L^ 7 -._—.. CONTRACTORiJ(T / WORKER.i COMPENSATION DECLARATIOi*,.' •- -, — 1 HEN F AFFIRM UNDER PENALTY OF PEFUURV ONE OFTHE FOLLOLNNG DEC.Al17( L� �� A i7)II / I HAVE AND WILL MAINTAIN ACEHTIFICATE OF CONSENO SELF -INSURE F RKFRS' COMPENSATKJN, AS PROVIDED BY SECTION 3700 OFT, L LABOR CODE, FOR THE PEHI�ORMANCF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. \\ _ I HAVE AND WILL MAINTAIN WORXERS' COMPF.NSATION INSURANCE., A9 RECUIRF.D BY SEOTIDi 37000F THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER.A CARRIER,_, POLICYNUMBER (IHSSECT)ONNEEDNOTBE.00NMPLETEUO`THE PEFPAIip ONEHIAAED-00)ORL- ? I CERTIFY THAT IN THE PERFORMANCE OF T'HE WORK FOR WHIQH THIS FE IT IS ISSUED. 1 SHALLNOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BE ME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THATJE GHOULO SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE L ABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: _- _ APPLICANT: --.---.__--- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (A1W.W ), 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 WUFIK FOR WHICH THIS PERMITIS ISSUED (SEC. 3097, CIV. C.). 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 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 INSPEC TION PURPOSES. f � f PEnMM%IKNAME(PRI )_ ,�4 \ _� _ _ � F SIG TURE OF P ' E DATE rf ) PRESS FIRMLY APPLICATION ' r( I�i, PERMIT LAY ,� P/C DATE U V NUMBER L' J # ISSUE TYPE OCC DATE 5 CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR U _ SIDE/SIDE STREET RW Cl SIDE U PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM Garage/Carport W Patio/Deck LL POOUSpa Z Re -Roof Commercial m Valuation -------------------- ADJ.AREA----------.--- ------------ -- QUANTITY DESCRIPTION FEE Q ! U V fL U W __ W /) cc J •Q • CON5.WWGPGP4 PLA REVIEW- ----------- '•-- --- `- -771 LIV BING I� PECTION FEE --� ISSUANCE- SMIP v'.:-:1 ENERGY P/C ENERGY PERMIT RETENTION FEE: C ,i;.--'�._--=---F---- - -- ----- PRE -ALT FEE: ----_. _...---...... ._ .... _._...__.___ .....- _--- TOTAL FEES _`� (� COMMENTS RECPT. NO-_ PAID BY ✓ VALIDATION WHITE -Department Copy, YELLOW -Finance Copy. PINK -Assessor copy, -Py, o.,c .. yP , —Hy _ ' _ ... - i� i i � � i i i � i i , .� �� - - .� � Wil, � ��. i - , � _ ..._ ... _..I _. ._, _. � s - �� — ' �� £ : �� - - - L '; - 7.. , 4 i �� .h• _ _ � f .":S � - - .T Jay ._ ._ _ _ - � - � { t