HomeMy WebLinkAbout10244 (7)CITY OF DIAMOND BAR
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COMMUNITY DEVELOPMENT DEPARTMENT
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21660 E. Copley Drive Suite 190
ISSUE Y l9 7
86ING 8PPLI 7
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BUILDING PERMIT APPLICATION
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OWNER
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CITY �.. �.� r ZIP TEL.
APPLICANT J I^*- TEL.�SSTKTKS�s l
CONTRACTOR S
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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
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MY LICENSE 15 IN FULL FOR E AND EFFECT. _2 g)
LICENSE CLASS
LIG. NO. Ole
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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.
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DATE _Z/
NUMBEPERMIIR
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ISSUE Y l9 7
TYPE
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DATE ^
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
REAR
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SIDE/SIDESTREET
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SIDE
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PROPOSED USE t,
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NO. DWEL. NO.
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NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
W
Garaga/Carport
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WPatio/Deck
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PoOVSpa
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470 a Ci o
Commercial
5
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Valuation
ADJ.AREA
OUANTITY DESCRIPTION
FEE
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Cr
13
LU
J
W
0
Z
J
6
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ONSTRUCTIO �
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL tib
SPECTION FEE
ISSUAN
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SMI
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ENERGY P/C _
ENERGY PERMIT —
RETENTION FEE_
PRE -ALT FEE
TOTAL FEES
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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
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