HomeMy WebLinkAbout15014CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION.'
JOBSITE
ADDRESS
APN LOT TRACT'
OWNE
A D D R E
CITY 14 TEL',
APPUCA T TE
CONTRACTOR 1P
ADDRESS
CITY ZIP 6r,T L.
ARC I NG/
DESIGNER -
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEIUURY THAT I AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.E BUSINESSAND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIIESA PERMrTTOOONSTRUCT,ALTER IMPROVE. DEMOLISH, OR REPAIRANY STRUC"
TURF, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS Ll -
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION ?DDD) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM ANDTHE BASIS FOR THE ALLEGED EOtEMP-
TON. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTSICA
THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (0oo).): . .
O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,'
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044, BUSI• .
NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF
PROPERTY WIO BUILD9 OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIUSELFOR HERSELF OR
THROUGH MS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FORSAIE. OF. NOWEVERTHE BUILDING ORIMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
' TON. THE OWNER-WLDER WILLHAVE THE BURDEN OF PROYINO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE). I i
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WtTHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW ). !
O I AM EXEMPT UNDER SEC B. t P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFI M UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
f (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
AI'/ LICENSE 6 N Ml FORCE AND EFFECT.
�� �' / z
LICENSECLASS UC. NO.
DATE . CONTRACTOR
WORKERS' COMPENSATION DECLARATION 1.1Tn�
I HEREBY AFFFW UNDER PENALTY OF PERJURY ONEOF THE FOLLOWING DECLARATIONS'V�
_1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CDNSENT TO SELFNN9URE FOR WORKERS'
COMPENSATION, AS PRONGED BY SECTION STDG OF THE LABOR COOS FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
�I HAVE AND WILL LUINTAN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
.700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'CdIPEN9ATpN INSURANCE C LER AND POLICY NUMBER E:
CARgt ify/S'-`/,i I�r,.1PI_LT'•11v
POLK'V NUMBER _ /_/ 14
IDG ® RMI
SECTION NNOT BE MWLETEDOFTHE PETS FOR �ON•ECrH4lOREDDOUARS WOO) OR LESS)
-1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHKH THIS PERMIT IN ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, ANDAGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COOAPENSATION PROVISIONS OF SE ION 3TO0 OFTHELABOR
COD S iOHTTIGW7N COMPLY WITH /�/i►P IONS.
DA APPLICANT: e
WAW O: FAILU TO SECURE NOiiKERS'CO0 P"'AT10N COVERAGE IS UNLAWFUL, AND SHALL BE
BUS,AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS
ISIW,OW), IN ADDITION TO THE COSTOF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 7705 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
-1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FON THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC SOHO, CIV. C).
LENDERS NAME
LENDERSADDRESS
I CERTIFY THAT I NNE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATNO TO BUILDING
R
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE .
ABOVE.MVNT0WED PROPERTY FOR INSPECTION PURPOSES_
ERMI 11T)
NR RMI7T E E
PRESS
APPLICATION
PE .. RII
APIC
DATE 1
NUMBE
ISSUE
TYPE
OCC V
DATE
CONST.
GROUP.'
ZONING SIEMACKS
FRONT
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REAR.
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SIDMDE STREET
RW
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SIDE
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PROPOSED USE 7.4
NO. DWEL. O.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ.AREA/VALUATION
SFR/ADD/REM
_
co
Garage/Carport
W
PatiwJDeck
�-
Pool/Spa
ZRe
-Roof
Commercial
m
Valuation Ljr ADJ.AREA
OUANTITY DESCRIPTION
-"
FEE
Q
UL
LU
C7
2
OD
a
_...
_. ..
2
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CONSTRUCTION
•
PLAN REVIEW
ELECTRIC.
L
PLUMBING
MECHANICAL - -
--
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
-ENERGY PERMfT
RETENTION FEE:
A
PRE -ALT FEE: f.�ry
t -1T TTT TA
A ,..
u
ITVi0FrjI�
TOTAL FEESjQ
` J IO
COMMENTS .. ..
.. i - .
a in
RECPT. NO. PAID BY
' `
V/WDATIONI
WHITE—OWartment Copy, YELLOW—Finance CGpy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant' Copy ..
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