HomeMy WebLinkAbout10070 (9)CITY OF DIAMOND BAR
COMMUNIT" DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION`
ADDRIESS 2 Of7 . S• rAf'I. L R
APN LOT TRACT _
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APPLICANT �,,,,�(roIN TEL. S3L8? &+2. "1
CONTRACTOR UK4 G0r.15r
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERAIRY 7HA- AM EXEMPT FROM TLE CONTRACTORS LL
J CENSE:A.WFORTHEFO'_LOWING REASON(SEC,7031.5 BUSIIESSAND PRO.=ESSIONS CODE.:ANYC.TYOR
COUNTY WHICH AEQUIRESA PERM:TTO CONSTRUC.'. AL'ER. %IPROVE. DeMQLISH, OR RFPA:RAVY 9TR'JC.
TUgE. PRIOR Tp;751%UANCE. ALSO REOJIRES Tr.E APPLICANT FOP S:.'CH 'ERM.T TO FILER S:CNED
STATENEhTTHAT:Ir DA SHE IS LICc Y9E0 PURS(;ANT TO THF PROVISIONS OF THE CONTRACTORS LF
E CENSELAW(CHAPTER 9400MMENCING WITH 9ECYKAN 70CC) OF D:V.SION SOF THE BUSINESS R% -)PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM A%D THE BASIS FOR THE ALLEOEO FXEMP-
TION ANY VIO,AT:ON OF SECTION 7031.5 BY ANY APPI.ICAN. =OR A PERMIT SUBJECTS THE APPLICANT TO
A CIV.L PENAL. Y OF NOT MARE THAN FIVE HUNDACD COLLARS,'SSOC;J:
71,'S OWNeRO:'HE:NiOPEgTY.Oq MY EMPLOY THZIRSC.ECOMPLNSATi
WILL 00 7NE WORE. AND'HE STRUCTURE :5 NOT IN I' NUSD OR OFFERED FOR SALE (SEC. TOM. Susi.
NESS AND PROFESSION5 CODE: THE CONTRACTORS LICENSE LAW DOES \O' APPLY TO A%' O'NNER OF
PROPERTY WHOBU, 05 OR IMPROVES THEREON, AND PJHC:OES SUCH WORK HIMSELF OR HERSELF OR
THROVCH HIS OR HER OWN EMPLOYEES. PWADED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FOR SIDE IF, HOWEVER, THE BUILDING OR IM -ROVE AWNT!SSO:A'AITHINONEYEAROFCOMPLE-
TICN. THE OWNER -BUILDER WILL ^AVE THE BURDEN O: oROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
LC i.ASOWNEROFT7EPROPER -AAM-S%CLUSIVE�YCONTAACTP:GV.YfHLICEN•SE�• CONT�ORS
TO CONSTRUCT THE PRO -ECT (SEC. -.341..BL'SIRE.SA AMC) PROFESSIONS CODE. TOE CO%TgAOTORS U.
CENSE LAW DOTS NOT APPLY TO AN OWNER OF A PROPERTY WnO BU., -DS OR IMPRDYES THEREON. AND
Y'Ho CONTRACTS FOR SUCH PROJECTS WITHACONTPACrORIS)LICENSSD m, R5UAN7 TOTHECOFrrgAC.
TORS LICENSE LAW]
FOR Iw,S REASON
DATE O%VNFR
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT, AM LICENSED U.kNR PROVISI NS OF CHAPTER
e ICOMME:NCING WITH SECTION 7000) OF DIVISION 3 OF TrIE BUSINESS AND PROFESSIONS CODE, AND
MYLICENS91S:\FULLFORCEANDEFFECT,
LICENSECLASS D4'b LIC. VO.
DATE. � I ?�� �`L CONTRACTOR
WORKERS' COMPENSATION -CLARATION
I HERESYAFFIRM UNDER PCNAL�. OF PERJURY ONE OFTHc FOLLOWING DECLARATIONS:
I HAVEAND WA-LMAWTAWACERTIFICATEOF CONScNT TO SEL;4wWRE FOR Yr WgS'
COM
PENSAT'ON. AS PROV;DFD BY SECTION 37CC OF THE LABOR CODE. FOR THE PERFORMANCE
OF TUE WORK FOR VIH!Cm THIS PERMI- IS ISSUED.
—1 HAVE AND WALL MANTAN WOAKL'RS-.)OMPE%GATION INSURANCE.. AS REQUIRED BY SECT:ON
3700 OF THE LABOR CODE, PORT•+E PfRRORMANC E OF -REWORK FOR WHICH TYJS P: RAPT 19
ISSUED. MY WORKERS' COMPENSATION IIN V,;RANCE: CARRIER AVD POLICY NUMBER ARE:
CARRIER _ `L'r'�"�''F rNL� In
POLICY W;MBER
(-HISSEC'IOMIEMN0'BCODM:_TEDOFTWPEFTLY'ISFCRCILHUNaREODoUSIf'WOFILESSL
1 CERTI-Y THAT -'.N TAE PERFORMANCE C - 'HE WOAK FOR WHICH TH.S PEPIN:T IS ISSUED
SHALL h'OT EMPLOY ANY PERSON :N ANY VANN-R SO AS'O BECOME SUB:ECT TO THE
WORKER ;•C.OMPENSATI: N LAWS CF CAL'170i", A%7 AG REE THAT IF I SHONJLD BECOME
SUEI:ECT TO THE WORKERS' COMPENSATION PROVIMO%S OF SEC7ION 370E CE THE LADOR
CODE. I SHALL FORTHV."lU COMPLY WITH THOS" VISIONS.
DATE: t _ APPLICANT. —
WARN!NG:FA'L'UR�CY_OSECCVV'REWORKEERS'C .PENSAT: VCRAGEE IS'%LAWFUL. AND$HALL Be
SUBJEGTANRMPLOYEATOCRIM.%'ALPENALTIFSII.N0C.. _FIhE5 UP 700.NE HONORED TOVS4h7
DOLLARS ($100,000). IN ADDITION 107HE COSTOF COMPENSArM, DAMABES AS PROVIDEO FOR IN
SECTION 37M OF THE LABOR CODE. INTEREST. AND ATTOR%EY'S FEES.
CONSTRUCTION LENDING AGENCY
I hEREBY AFFIRM UNDER PEhM,TYOF PEFL aRY THA7 THERE IS A CONSTRL_TrON LENOINO AGEhc-Y
FOR THE PERFORMANCE OF'H"E WORK FOR WHICH THIS PERMIT IS ISSUED ;SEC 3467, C:V. C.}
LENDERS NAME
LENDERS ADDRESS
I CERTIFY -HAT I HAVE READ THIS APPLICATION AND STATE TUAT. TY.EABOVE.%FORMAT om IS CORRECT
I AGRE9 TO COMPLY W!Trl ALL CITY AND CW NTY ORDINANCES AND STAT: LAWS RPLA71NG -0 BULO'NC
CONSTRUCTION. AND HEREBY AUTHORTCE REPAESEhTATI VCS OF TH:S COUNTY TO ENTER UPON THC
ABOVEMENTIpNEO PFK]PERrY FOR INSPECTION PURPOSES.
PERMITf NAM
SIGNA OFPERMI:TE — ._._��A_E.3- ""•
WHITE-Departmern Copy, YELLOW-Fhanoo COPY. PIN
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PRESS
PIPUI v
PERMIT f �y� ` /C
APPLICATION1-4/-?7
DATE S ' 4 f - ? % NUMBER r i 1V #
ISSUE TYPE OCC
DATE--___ CONST. GROUP
ZONING SETBACKS
FRONT RW r
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PROPOSED USE
rSTFLtP� H•C. ARI�r
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. Fr. FACTOR PSI= ADJ. AREANALUATION
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ENERGY PIC•' -
ENERGY PERMIT
RETENTION FEE: - - _ '•-jD.:
PRE -ALT FEE:_ -
TOTAL FEES
COMMENTS
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RECPT. NO- PAID BY r VALIDA110
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CITY OF DIAMONO BAR
MSPECT01N RECORD
SET BACK1. LOOK JOIST
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7-:77 —.
ELECTRIC :.7DEV. FFES PAID
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I CONOXENTS
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7-777 -------- - .77
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