HomeMy WebLinkAbout15148CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
+°: 2 21660 E. Copley Drive Suite 190
(909)860.3145 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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CITY ZIP ,moi TEL%
APPLICANT TEL.
CONTRACTOR GFP 2 ( ti F/'
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DESIGNER
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CITY ZIP _ TEL.
OWNER -BUILDER DECLARATION
I HEREaYAFFrRM UNDER PCNALTY OF PEFL'VRY THAT i AM EXGMPT FROM THC CDNTRACTORB LI.
"NSE LAW FORTNE FOLLOWING R.-ASON (EEC 7957..': BUSINESS MD PROFESSIONS CODE: ANY C.TYOR
OOUNTY WHICH RE41IRS SAPERMCrTO CONSTWCT, ALTER. IMPROVE, DEMCLISI I, OR REPAIR ANY S79' C-
TURE PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPL:CANT FOP. EI;CH PERM.T TO FIIE A $IGN'cD
STATEMENT 7HA7 HE OR SHE IS UCEN•SED PURSUANT TO THE PROVIS:ONB OF THE- CONTRACTOg9 L'•
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 700.; OF!)!VIS.O.% 3 OF THE O',SINESS AND PRO•
FES910NS OODE) CR THAT HE OR Stg IS EXEMP: THSREFROM MO THE BASIS FOR THE ALLEGED EXF51P•
TOCN. ANY VKO ATKON OF SECTION 7931.5 RY MY APPUCAN. FOR A PERMIT S�SJF.C:5 -HC AP �_:CAN'T:C
AGIVLPENALTY OFNOT MORE THAN FWF HUNDRED DOLLARS MOO):
:I,ASOWNER OFTHE PROPEERTY, OR WV EMPLOYE:$ WT} WAGESAS THEIRVLE COMPENS.IT:ON.
WILL DO THE WORK. ANO 11 THE STAUCTURE IS NOT INTENDED CR OFFERED FOR SA:E (SCC. 79A4. B:;SI.
NESS AND PROFESSIONS COOE: THE 0RACTORS UCCNSE LAW ODES N'C'. APPL" TO AN OWNER OF
PROPERTYV040 BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH 1415 OR HER OWN EMPLOYEES. PAOVIDED THAT S:OG+ IMPROVENCNTE ARF NOT INTENDQa OR
OFFERED FOR SALE.IF, HOWEVER THE BL':LIiNG 0,'1IMRAOVCMENT:5SOLD W ITH:N ONE VEAR OFOCMPLE
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING 'HAT HE OH SHE DID NO- DV:LD OR
IMPROVE FOR THE PURPOSE OF SALE).
_ L AS OWNER CF THE PROPERTY, AM EXCLUSNELY CONTRACTING WITH :ICENSFD CONTRACTORS
To CONS rW-'CT THE PAoJBCT (SEC. 7044, BUSINESS Av0 PROFf MO.N$ CODE.: TH° CM -RAC -0,9S J -
CENSE LAW DOES NOTAPPLYTO AN OWNER OFA P.AOR'RTY W✓O gU2DS OS rXOPOVES' TYEREDN, AND
WHOCONTRACTS FOR SUCH PRC.:ECTS W:: d ACONTRAC'O.a(S! L.CENSED?URS:iANT!; ME G -RAG
TORS LICENSE LAW.,.
C: I AM EXEMPT UNDCP SEC. B. R P.G. FCR'HI<_ RE.SO7'!
LICENSED CONTRACTORS DECLARATION
I HERESYAFFIRM UNDER PENALTY OF PEw.1RY :TiAT:AN7_ICENSED'UND F. ?RCVISYITIS OF CFAP7E8
Y (COMMENCING WITH OF D:'i!SION 3 OF TSE VUS:NESS AND PROF=sS ONS -00F. ANO
MY LICENSE MIN �,11L %O`RCC AND _-FFECT.
LICENSE CLASS �+ LIC. NC._9i 1
DATE CCNTRACroR /YI [(•" 11_ TG''�
�r
WORKERS COMPENSATION DEC ATI(iFv
F'
IHCRELTYhFFIRM UNDER PENALTYCP PE:{,,;Rl CNc OF:_O GLAR
_!HAVEANDW!LLMAINTAINACERTIFICA'EOFCO.'1i NT TO 69LF •ti �P--OR WORKEP5J
COMPENSATION, AS PRONGED BY SECT.0% j7.7O%''PIB�iL.P.1"COC. FOR T . R-
OFTHE WORK FORWHiCkTHIS PEHM'T 15 ISSUED. -'�'�•'""'"
i.rAVE AND WILL MAIh:A:N'WVCRNCRS' COMPF.NSAT CN INS_RANCE. A'!; RED::P. SY SF- N,— -
3,mrF'HELASCRCODE,FOR7H=PERFOA6'ANCEOF7HFWORKF,.A'RHCH.Y' _RMITIS
IS,1:d:D NY VJORKEHS'COMMPy'C'mSSATIOn.N R�•Ni.('AP.R:CH AND P_ -ER AAE:
CARR:ER _—S��c..{' A�-
POLICY M:MBER _.,_ �_�—L._ 0
!THS SECILN NCeiNOTE:EOUAP-E':D"i Q'r EPEkAT:i FOR CAf:G,4D."+ED DO •OC!ORL .y
:CEPT;FY THATM THE PERFORMANCE r TI I- WOnK FOR Jr:H'M°YEPMI"' 'SSULD.
S:!ALL:JOT. EMPLOY ANY PERSON IN AW MPNNEP.SO Ac �O LCOM'c iVL'.:ECY `:: T:IE
WORKCAVCOMP?NSA7:OTILAWSOPCAL!FCHN!A,ANOACREy ,ATIF15HOUIL!)VECxDVr.
SI:B.EC:'70Y.0 WORKER�COMPENSATK)N 7-CV!SANS OF EL n0N :TCC OF--E'l.BCR
CCD'. I SHA;.L FCR.r,&"_H l'0" LY MS TH T S' PRO�'J1:JS:ONS. l'�~
IDATE:APPL'OANT:�,`-'�
WAFLNING: FA: W RC'O SECUAE'AURKER'.T COM. ENS.'TK)N C0VERA3E.S UYLAVIFI;_. ANO SHALL BE
SUW9CT AN EMPLOYER TO CRACNIAL PEN.A'-T:ES AND CNIL F.NES UP :C CNE HUNDRED -r:CUSANO
DOLLARS i$"00.mm,., IN ADDIT•ON TO THE COS'OF COMPENSA'.IO,, DAMAGES AS PROVIDED FOR IN
SECTION37cS OF -HE LABOR CODE. INTERES.. AND A:TOHN'E $FEES.
CONSTRUCTION LENDING AGENCY
I HEAEBY AMARA u.NU ER PENAI'Y OF PCR.UP.Y THAT Tr -ERE IS ACCNi R;;CT'ON LENDING AGENCY
FOR TIIE PERFORMANCE OF -9 WORK FOR WHICH TH'S PERMT IS 195L ED ;SCC. DOW. C:V. C.).
I
LEND`PSAOORESS
I CiRTRYT 1TINA11E HEAD THIS AIR"ICAT--D STATE THAT 7HEABCVE _NFORMA: ON:S CORRECT.
% ACRE£ TO COMPLY WITH ALL CT• AND CO',.N7Y ORDINANCES AND STATE LAWS RELAT IG 70 BUILDING
CONSTRCCTION,AN9HEREBYAUTHORIZE.P.EPFiE SI TATNEs OFTH S COUMVTO-ENTER UPON -HE
ASOVGMENTION-3PROPERTV FOR:NS�ECTION P:RPOSES.
i PFRM'i
$ICN OF PERMIT=_E IJDATE
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PRESS
FIRMLY
APPLICATION I ^Z sL t j! ET
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DATE � I ' NUMBER
NUMB#
ISSUE `j J� TYPE OCC
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DATE + 1, — CONST. GROUP
ZONING SETBACKS
r _ RW —
iFRONT
REAR
SIDEISIDE STREET RW
LJ SIDE —
PROPOSED USE _III
NO. DWEL. / ` IVO, No
UNITS STORIES — BEDROOMS
!
DESCRIPTION SQ. FT:
FACTOR PSF ADJ. AREA VALUATION
SFRrADD/REM
CC Garage/Carport
Pam,`Deck
1
LL
Poo)ISpa
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Ro-Raof.
Z5
CIommercid
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ENERGY PERMIT _ •_._
FIFEE:
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ORE -ALT FEE:
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4j TOTAL FEES
COMMENTS
3
R PAID BY VALIDATION
WHITE-Depanmen! Copy. YELLOW -Finance Copy. PINK-Assesw Copy. GOLDENROD --File Corry. GREEN-Apphcant's Copy
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