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HomeMy WebLinkAbout10244 (7)CITY OF DIAMOND BAR �g / COMMUNITY DEVELOPMENT DEPARTMENT ! 21660 E. Copley Drive Suite 190 ISSUE Y l9 7 86ING 8PPLI 7 OCC ERFax IT BUILDING PERMIT APPLICATION BLU e JOBSITE A pj .-:�:. I D ADDRESS APN LOT TRACT OWNER ADDR SS 6 L CITY �.. �.� r ZIP TEL. APPLICANT J I^*- TEL.�SSTKTKS�s l CONTRACTOR S ADDRESS j �✓'- a '✓°'.- 7�.- a �-.a `� e, CITY ZIP °71"!, TEL. SSa aC->�i ARCHIENGI DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CFNSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH REQUIRESAPERMITTO 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 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O 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 7031,3 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): ❑ 1, AS OWNER OF THE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATOR WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 7016, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES N07 APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLO WITHIN ONE YEAROFCOMPLE- TIM. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O L ASOWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. CENSE LAW DOES NOTAPPLY 10 AN OWNER OF A PROPEflTY WHO BUILDS OR IMPROVES THEREON, AND W-OCONTRACTS FORSUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANTTO THE GONTRAC. TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. _ B. 6 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HERE13YAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION TOW) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND 4 MY LICENSE 15 IN FULL FOR E AND EFFECT. _2 g) LICENSE CLASS LIG. NO. Ole f DATE C CONTRACTOR 0 ""— S C.4 -k_ IGN r' WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATK)NS: _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF4NSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS RE-OUIREO BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS CARRIE. M RKE,RS' M N INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER `,ATI POLICYNUMBER 44AY ti (V sv (IHIsSECRON NEEDNOTSE OMFLETEDOFTHE PERrATIS FORONE RACREDD=ARSMOD)ORLESS} 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO 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 C////ODDE,,,. �II SHALL FORTH WITH COMPLY WITH E P$OVISIONS. LIP DATE: APRICANL WARNING: FAILURE TO SECURE WORKERS' CO ATKON COVERAGE 15 UNLAWFUL. AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ISI 00.000). N 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. 3007, CIV. C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY MTN 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. PE RI �� S ` SIG OF ITTEE I !Ln ATE PRESS FIRMLY CATION q �g / DATE _Z/ NUMBEPERMIIR #� ISSUE Y l9 7 TYPE OCC DATE ^ CONST. GROUP ZONING SETBACKS FRONT RW REAR C SIDE/SIDESTREET RW C SIDE ❑ PROPOSED USE t, Nr - `' c a • W . E9 NO. DWEL. NO. `T— NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM W Garaga/Carport _ WPatio/Deck LL PoOVSpa Z'Re -Root l9v 71 470 a Ci o Commercial 5 00 Valuation ADJ.AREA OUANTITY DESCRIPTION FEE J U Cr 13 LU J W 0 Z J 6 U_ Z Q U Cl ONSTRUCTIO � PLAN REVIEW ELECTRIC PLUMBING MECHANICAL tib SPECTION FEE ISSUAN -� SMI ' 4 ENERGY P/C _ ENERGY PERMIT — RETENTION FEE_ PRE -ALT FEE TOTAL FEES g y COMMENTS RECPT. NO. g 3 % PAID BYe{/Z j� ry r VALIDATION WHITE—Department Copy, YELLOW --Finance Copy, PINK—Assessor copy, GUWF=Nrwu—+Re L:Opy. UHEt:N—Apglcanrs L:opy MA,