HomeMy WebLinkAbout16257 — - �'-'� � 1
� CITY�3F DIAMt3ND BAI�t /� J
DEPARTMENT OF CbMM[JNITY&DEVELOPMENT SERVICES / �
� 2 i660 E.Copiey Lkive Suite 190 /)
" (909)860-3195 Fax(909)861-3117 �/ �Ss
"*�"" BUILDIlVG PERMIT APPLICATION � � FIRM�.Y
� JOBSITE ����.,� ^J. [}IAE'ID�II� �R R�L-VD . DATEICATIQN � `���� PERMIT `� a�'��#/C �� r��
o ADDRESS.,.+„_�,� �� NUM6ER� `
g ISSUE TYPE OCC
APN uL�O,T TRACT DATE GQNST, GRp�p
p OWNER _ .l1S.--.�VPt,"t�Y1. �..-I,-�. _ ,
o ADDfiESS '� W i I�Ic � ZONING SETBACKS
W CITY I/ ZIP O D TEI. 3I�+'"' � FRONT _ RW Cl V_
� APPLICANT �" TEL.�._"�,y�,'-1 REAR ❑ —
�`�� SIDFJSIDE STREET , RW ❑
� CONTRACTORA SIQE �
t]C ADDRESS
Q CtTY � ZIP TEL. PROPOSED USE Ca,�' (' +/ J
� ARCH/ENG!
� DESlGNER NO.DWEL. NO. Y NO.
� ADDRE5S UNITS STORIES BEDROOMS
= CITY ZIP 7E�.
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u� DESCRIPTIQN St}.FL FACTOR PSF ADJ.AREANA�UATlON
� OWNER•BUILDER DECLARATION SFR/ADDIHEM
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Q I FIEFEBV APFlNM UMJEA PENAITV OF P�RJtiRV THAT i hM£XEMPT FROM TH£COMTflACTORS L4 �a�BgeJCd1p01f
Lt,i CENSELlWFOR7HEWllfYNiN4HEASON(SEC.ltl:f1.5@USINESSANDPRQFESSKINSCQ6E:ANYCINOR ((�
�..� C9lMJiYYMHICHREIXlIRESAPERMITTOCQYSTRUCT,ALTER,MPpOVE.DEMOLISH,pRREPAIRANY57RUG �
�" ttIRE PRIDR TO ITS IS9UIWCE.A150 REQUIRES THE APPUCANT FOR SUCM PEAMIT TO FiLE A S�GNED PatiWDack
� STATEMENT TNAT HE OR SHE IS UCENSED PUitSUANi TO TNE PROVISbMS OF 7NE CONiRACTOf1S LI- W
GENSE lAW(GIAt+TER 4{{YMiMENGNti W17N SECTKXI 7o�P)tlF W VISIOFl3 oF THE @USINESSAND PRO- u' PQOUSpa
FES:3pN5COpE)OR7HATHEOHSHEISE7(EMPTTMEREFqUMAN�7HEBASISFORTHEPLLEGEDEXEMP- (,r}
TION.ANVVIOI./RIONOFSECTION7031.5BVANYAPPLICANTFORAPERMITSU&IECTS7MEAPPUCFNTTO Z Re-Raoi
� ACn/ILPENALTYOFNOTMORETHANFIVENUNDREBOOLtAFiS{Z5W}.j:
� fli,A50NMER#TNGPflOF+ERTY,ORMYEMPLOYEESWITHWPF3E5ASTMEIRSOLECOMPENSATION, �pmmg�ClHl
WILL.DO TME WOpK,�Np THE STRUCTURE IS NOT WTENDED OR OFFEAED FOR SALE(SEC.7p44.OUSI- O
� NESS AND DROFESSIaVs GODE:hIE CONI'MCTqR3 UCENSE[AW DOES NOT APPCY T6 AN oYtNER OF = ���
PRDPEIRY WHO BUIi.DS G�R IMPROVESTHEREptt,ANO WNOOpES SUCH WORK HIMSE1FOft MEflSEIF OR
�' TMROUQH HIS QR HEfl pMM EMPIOYEEB,PROYtOED THAT SUCk IMPROYEMENTS ARE NOT INTENOEO OR m
�3a 6FFEflEOFOR$AI,.E.IF,FIOWEVEFi,7HEeUI�pINGORIMPqOVEMENTI5SO1DWI7HINONEYEAROFCOMPLE
� TION,THE OWNER-BUIlD1=R WILL HAVE iHE BURpEN OF PROVINCa THAT HE Oq SHE Dp NOS BUItD OR
� 7M9ROVE FOp 7tiE PUAP6SE OF SAt.E}.
�y,� ❑i,ASOWNEROF7!{FPF�pEATY,MIEXCLUS1YElYWN7RAGTINpWITHLICENSEDCANTRACTORS ..
d TO COMSTqUCT 1HE PRCUECT(SEC.7041,OUSINESS AND PRUFESSIONS WDE:THE CONTRACTPRS G- V8IU8t10� �ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANbNRtEROFApROPER7YWHq8UILDSOfiiMPflOYE55NERE�N,RND ��V
� XM1ACONtRACTSFORSUCFtPRO.tECTSWtTHACUNTRAC70R(5)tiCENSFDPU}iSUANTTOTHEGONTAAC� QUANTITY IPTION FEE
X TQRSUCENSEUW.).
� ❑I AM EXEMPT UNDER SEC. ,_, _�.d P.C.FOR THIS ftEASGY Q .�,� 4��
� � � '� �. ' �,� t � �.
� DATE OWNER,_ Y L?
� �— � �c. �f' , C:1...
� UCENSE�CONTRACTdRS DECLARATION w i�
� �J �c ��.�
I tiEREBY hFFRW l7HDER PENACi'Y 6F PERJURY THAT tAM IiCENSED UNDEH PROVISIONS Ot CHAFTER �
d Y(COMMENCIk4 WIM SECTKNJ T4W)bF bIY1510N 30F THE 9USINE55 AND PROFESSIONS COOE,ANp �
il� A/Y LICENSE I51N FULL FoqCE AND EFFEC7, m
� LICENSE GIASS_ LIG.NO..� j
� OATE _ CpNTRACTUR _ � � ��—
� WORKERS'CpMPENSAT10N DGCLARA7ION �
� I HEREBV AFFIRM UNDER PENAL7V OF PERJURY ONEOF TNE FOItOWlNG DECtARA7iON5: Z
� ._,^,_IttAVEANOWIttM�1NTAMIACEATIFiCATEOFCONSENT70SElF-INSUREFOpWORKEPS' _ �
CXJMPENSATlp�,AS Pfl4VIDEp BV SFCTION 3]DO pF THE 1A60P CODE.FOR 1HE PERFORMANC6 �
O OF THE WORK FOR WMICH THIS PfRMIT IS I$SUEO. �
W _�li+iYE M7D WIl.L iNAiMAitJ WOHKERS'GO#iPENSA7tON iNSUfiANC6,AS REOUIftED BY SECTIOM
O a7W 4K TNE t.UB(5F!^AUE,rOfi TNE PERFORMMICE OF THE WORK F4R WHICH THIS PERMIT IS � �1 �� , �f i
I$SUED.MY Wf�RKERS'CJOMPENSATION INS�RANCE CARRIEH 1Np POUCV NUMBER ARE: GONSTRUCTION .t�—}=^--'�-1"—�—— .f�' ._�
j C:wr+�Ex.,_„ . _._ , PLAN REVIEW J `
z aoucvnuMsra_ _ EtECTRiC _._., '�-��
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� R�sEt:tinNNEFAtJC'i78EIXa14�tEifDOF7ifaERAri�F".,ftoNE�0.A.Di7EUo�llnRs451o0)�ftLESS� PLUMBING _._.._...
z l CERTIFY 7HA.T IN THE PERfOpMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,1 MECNANICAI. ,.
C} SHPLL NOT EFAPLOY ANV PERSON 1N ANV MANNER 50 AS Tp BE WME SUBJECT TO Tt{E �
{/� WORKERS'GbF.iPENSRTiONUWSOFCAtiFORt+�A,AND0.GFEETtt4TiflStiqULDBECAME � INSPECTIQNFEE
S41&7EC7T01'HE WQRKERS'C:OMPENSATN?N PROVISIONS�F SECTIpN 3700 OF THE LABOP
� CODE.ISNALF6RTHWITNGY7MPLVWITNTHQ6EPROVISICINS. (SSUANCE _! � �_.�
Q {�-I�+�,
DATE:_ APPLiCANT. � SMIP ' `,�`l _.v
� WAflNiNCa:FAIIURE T'J SECVRE WORKERS'COMPENSATION CAVERAGE IS UNLAWFVL,ANp SHAIL B[ ENEFIGY P!C �f�j�.�_..
�y, SU&IECT AN EMPLOYEFi 70 CRIMINAI.P[NALTIES PND CIVIL FINES UP TO ONE HUNpflED THOUSAND ENERGY PERMIT
DOLL,AftS(�100,006j,INAUDiTItlNTOTHECOSTOFCORtPENSATbN,QAMAGESASPRQYtOEDf4ftiN --�� _. -��t� �
� SECTION 37680F TiN_tR80R CDOE,INTEREST,AND ATioaNEYS EE£S. �"
aC RETENTIQN FEE: ) ���.,,;
OCONSTRUGTION LENDING AGENCY PRE-ALT FEE: �--�� .._...�,.—.._
� I NEREBY AFFIRM UNDER FENAITY oF PERJURV TNAT FHERE IS ACONSTftUCT14N�ENDING AGENCY �
FQfl THE Y�Rf-0RMMlCE Qf THE WORK fOA WHIGH THIS PFRMIT IS ISSUED(SEC.709�,CIV.C.). �
� _ , ..,�a�_-..-.---�.
� LENDEH'SNRME_ _.. _.__ --� �
F— L,ENOER'S ADpRESS
� ICfRTtFYTH0.TiHAVEAEA6TM5APPliCAT�ONAN�5TATETMATTt4EA80YE1Nf"ORMATlON15CORflEGT. TOTAL FEGaJ ��� �+ ��
W i AGREE TOIXNAVl1'W1TH ALt GITYAND CAUNTY C�RDINANCES AND STATE LAWS RELATING TO BUIL�ING
� CANSTRUCTION,MIDHEREBYAUTHURIZEPEPRESENTATIVESOFTHISCWNTYTOENFERUPONTHE
�,. ABOVE�MENTK)NEO PRUPERTY FbR MSPECTION PURPpSES.
0 COMMENTS,
�
PEp1AITTEE NPME{p{vNT)
� —..��. _ ��_��. � �
�fiiNATUflE OF PEIiMf7TEE pA7E i
� RECPL NO. _PAID BY 1+'� _ VALtDA7tON
WHITE—Department Copy.YELLpW--Finance Copy,PINK—Assessor Gopy,GOLDENROD—Fi�e Copy,GREEN—AppiicanPs Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUII.DING PERMTT APPLICATION
JOBSITE
ADDRESS I4o�S• ptAl�lo1JD�P.R P�L•V17.
APN LOT TRACT
OWNER L-LC•
ADDRESS-
CITY�/ZIP 0 TEL. �3"
APPLICANT
�IZ j Y�TEL. -����--
.�-1
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER•BUILDER DECLARATION
I HEREBY AFFYOA UMJER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLAOWINO REASON (SEC. 7031.5 BUSINESS AND PROFESSKONS CODE:ANV CITY OR
COUNTY WHICH FIEOUIRESA 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 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER Y((XJMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS OODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TKNV.ANY VKX_ATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ I,ASOWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES ASTREIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS N07 INTENDED OR OFFERED FOR SALE(SEC. 7014, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHp BUILDS GR IMPROVES THEREON,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 SOLD WITHIN ONE YEAR OF COMPLE-
TKXV,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PRCUECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTFUCTS FOR SUCH PROJECTS W ITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER_
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEPJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT,
LICENSE CLASS LIC. N0.
DATE_CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATK)NS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 3]00 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE U1BOP.CODE, FOR THE PERFORMANCE OF THE WOPo(FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATON INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
{IHLS SECTlON IJEED N07 BE C(N.f'LE7ED OFTI-E PERAYT 4S FOR ONE FO.IFDRED DOLIAPS(f100)OR LESS
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT LS ISSUED, 1
SHALL NOT EAAPLOV ANY PERSON IN M1Y MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'C(MIPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO I"HE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: i APPLICANT:
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL BE
SUBJECT MI EMPLOYER TO CRIMWAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f100,000j,IN ADDITION TO THE COST OF COMPENSATKV, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UND ER PEN ALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 309],CIV.C.).
I
LENOEWS NAME
LENDER'S ADDRESS
I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATK)N IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,MID HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
I
PERMIT7EE NAME(PRINT)
�IGNA7URE OF PERMITTEE DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOI-DENROD--File Copy,GREEN-Applicant's Copy