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Home My WebLink About17235 (10) 4 � CITY OF DIAMOND BAR r '� - DEPARTNiENT OF COMMUNITY&DEVELOPMENT SERVICES � �` ,w� 21825 E.Copley Drive f / (� pRESS (909)860-3195 Fax(909)861-311'7 \I �. "'%.car� BUILDINGPERMITAPPLICATION �I Y� �� FIRMLY � JOBSITE APPLICATION PERMIT -�t '"' � f P/C� o ADDRESS�(�Z ��L�� DATE �'«�� NUMBER�� #I i�g ISSUE j i TYPE OCC � APN L��T TRACT DATE ��1 � � I� I CONST. GROUP p OWNER�a�'L-- � A�,.�, �` , 4�p ZONING SETBACKS o ADDRESS=�,��L-- �10 Z CITY 1��ri-� ZIP9�c��EL� •qSS'OI) FRONT RW ❑_ � APPUCANT o0 2� L. REAR ❑ o ��-b SIDElSIDE STREET RW ❑ ¢ CONTRACTOR SIDE ❑_ � ADDRE S •0�.� �,J PROPOSED USE_O�'l �� 'r''� ' � CITY ZIP EL.��/�'��3 w ARCH/ENG/ -/ Z DESIGNER �flN�aln E�� • NO.DWEL. �� NO. NO. a ADDRESS '*-�� ! UNITS STORIES BEDROOMS � CITY C►Jr��oi.1.(y� ZIP��p TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I h1ERE8Y AFFIRM UNCIER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS L'- GBfd J8/CBfPOfS W GENSELAWFORTHEFOLLOWINGREASON�SEC.7031.5BUSINESSANDPROFESSIONSCA�EAN�CITYOR (n ZCOUNTYWHICHHE�UIHE5/1PERMITTOCONSTRUGT,ALTER,IM7ROVE,�EMOLISH,ORREPAIftANYSTFUC- W patio/�eck w 111RE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH�ERMIT TO FILE A SIGNED w STATEMENT THAT HE OR SIiE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTFACTORS LI- � CENSE LAW(CHAPTER 9(67MMENCING WITH SECTION 7000�OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSpO � FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� V TION.ANVVIOLATIONOFSECilONl091.5BVANYAPPLICANTFORAPERMITSU&IECTST4EAPPLICANTTO Z Re-Root A CIVIL PENALTY OF NOT MORE TNAN FNE HUNDRED DOLLAPS(5500).): O ❑I,ASOWNEROFTHEPROPERTY,ORMYEMP'.OVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COff1R1BfCIaI (' Z WILL DO THE WOflK,AND THE STRUCTl1RE IS NOT INTENDED OR OFFERED FOR SALE(SEC.�044,BU51- J NESS AN�PROFESSIONS CADE:THE CONTRAGTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTVWHOBUILDSOFlIMPROVESTMEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELfOR m � THROUGH HIS OR HER OWPI EMP�OVEES,PflDVI�E�THAT SUGH IMPROVEMENTS AflE NOT INTENDED OR W OFFEREDFORSALE.IF,HONIEVER,THEBUILDMGORIMPROVEMENTISSOLDWITMINONEYEAROFCOMPLE- � TION,THE OWNER-BUILDEfi WILL HAVE THE BURD'cN OF PROVING h1AT HE OR SHE OID NOT BUILD OF Z IMVROVE FOR THE Pl1RPOSE OF SALE). � ❑I,ASOWNEROFTHf:PROPERTv,AA�E%CWSNELVCONTMCTINGWITHLICENSEOCANTflACTORS � TO fANSTRUCT 7HE PRQIEC7(SEC.704a,BUSINESS AND PROFESSIONS CODE�THE CONTRACTORS LI- V2IU8tI0f1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPER7VWHOBUILDSORIMFROVESTHEREON,AND � WHOCONTRACTSFORSUCHPFOJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAF QUANTITY DESCRIPT�ON FEE Y TORS LICENSE LAW.). O B.&P.G.FORTHIS REASON Q ❑I AM EXEMPT UNDER SEC. � � LL �ATE OWNER ~ Z W � LICENSED CONTRACTORS DECLARATION w d � I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9(COMMENCINGWITMSEGTION]000)OFDIYISION30FTHEBVSINESSANDPROFESSIONSCOOE,AND Z `X MY LICENSE IS M FULL FORCEAN�EFFEc7. m O ��i � � UCENSE CLAS/$.. '� LIC.NO. � U DATE�L�LIL�O I CONT ACTOR a w r ' 1 � WORKERS'COMPENSATION�ECLARATION � Q � U � IHEREBYAFFIRMVNDERPENALNOFPERJURVONEOFTHEFOLLOWINGDEGLARATIONS: Z � I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSENT TO SELF-INSURE FOR WORKEflS' S COMPENSATION,ASPROVIDEDBVSECTION3]DOOFTHELA90RCODE,FORTHEPERFOiiMANCE U Q �FT iWMIGHTHISPEFMITISISSUED. � O w I NAVE AN�WILL MIAINTAIN WORKERS'COMPENSATION INSURANCE,AS NEQUIRED BV SECTION 2 /.� Q 3]Oo OFTHE IABOR CODE,FORTHE FERWRMANCE OFTHE WORK FOR WHICH THIS PEflM1T 15 ' 7 I�' �V ISSUED.MY WORNERS'COMPENSATION INS'JRANCE CARRIER AND POLICV NUMBERARE�. CONSTRUCTION j PLAN REVIEW _ GARRIER 0 POLICVNUMBER,��w�Q� 338 ELE(i`TF{�(�` Z Q � (iHISSEClqNNEH)NO78E�+1FLEfE�OF"1EPERMfTISFORaNEHUNDREDDOLLARS(S'�)ORLESS). PLUMBING w I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PEFMIT�5 ISSUED,I MECHANICAL L—'� �� Z ('} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECOME Sl1BJECT TO THE � WORKERS'GOMPfN5AT10NLAWSOFCALIFOfiNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE __. v SUBJECT TO THE'NDRKERS'COMPENSATION PROVISIONS OF SECTIOY 3]DOOF THE LABOfi � CADE, SHALL ORiHWIiMCOMPLYWITHTHOSEPRo IONS. ISSUANCE � DATE: � ____ SMIP ,I • �i/r i w ENERGY P/C 'J WARNING:FAILURE O SEGUFE WORKERS'COMPENSATION CAV[RAGE IS L'N✓WFUL,AND SNALLBE J � SUBJECTANEMPLOYERTOGFIMINALPENAL7IESAN�GIVILFINESL'PTOONEHl1NDRE0THOUSAND ENERGYPERMIT DOLLARS(5100,000).IN ADDITION TO THE GOST OF COMPENSATION,DAMAG'c5 AS PflOVIDED fOR M (✓. J SECTION37a00FTHELAEIORCADE,INTEf7E5T,ANDATTORNEV'SFEES. RETENTIONFEE: ..._ Q � CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O Q IHERE9VAFFIHMUNDERPENALTVOFPERJURYiHFTTHEREISACONSTRUCTION�ENDINGAGENCY n- fOR THE PEFFORMANGE OF THE WORH FOR WHICH THIS PEflMITI5155UE0(SEC.3091,CIV.C.). Z w � LENDER'SNAME_ - F— IENDER'SADDRESS �ry/ w I GERTIFY THAT I HAVE RE:AD THIS APPLICATION AND STATE THAT THEABOVE MFORMATION IS CORRECT TOTAL FE ES `�D/ ✓��`�v � IAGREE TO COMPLY WITH qLL qTV AND COUNTYORDINANCESAND STATE UWS RELATING TO BUILDING CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF Tl115 GOUNTV TO ENTER UPON TNE � �/�' o� ZABOVE-MENTIONED PRO��EflTV FOR INSPECTION PUfiPO5E5. � COMMENTS � � � � m � s� �-/r-o.l ' � 5 URE F PEFMITTI=E DATE J U � RECPT.NO. PAID BY ALIDATION � , WHITE—Depanment Copy,YELLOW—Finance Copy,PINK—Assessor CoDY,GOLDENROD—File Copy,GREEN—ApplicanPs Copy u i � �t�a,-� � �%� > ` M3��„,� . � ��,��"�. � ' '�D 7 2-d� ,�'E� ,. . r �4��,�-cl �i"Z � . ' �� _ � �M� _ �• � ..,E ��a�..�P,-�z �� _ _ . _ _ _ _ _ E , . . . . . . . . .. ... . .. ... . ... . .._ ._ .. . .. . ._... .__. ._.._ ..._ ..._.. . ... . . '�: , ,. .,.. � ,.. ,�,.. _ . . .... ..... ... . . . .. . . _.. . � .i: ,. _ , a . ... . .... . .. . _. ....... _.. .. . . i, �` _,., :�' . . . . . .... . .. . . . . . . . .._.. ... .. .. . . .. .. .... .. .... � ��i �" ��[� i�� , � `�� w � � , �� „ t . _ , '''� € »�, �� . ��: ' �.>��' — � ,��` � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES 21825 E.Copley Drive (909)8603195 Fax(909)861-311'7 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE//�� ADDRESS�� n'1��I3'L�� APN UDT TRACT OWNER-�a�a'�-- � ADDRESS��L,-�� '�p CITY 1(��1r4�ZIp��EL�-q SS O1) APPLICANT��-b o0 2�L. CONTRACTOR ADDRE S•0, CITY ZIP°I Z�i"�JEL. 7q� �� 3 ARCH/ENG/ DESIGNER ADDRESS� CITY CJJtA�to�l(�ZIP��p TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNCIER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV 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 OF 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 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): ^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH 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 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OFI 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,HOMIEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDEF7 WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^I,AS OWNER OF THf: PROPERTY,AM E%CLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MV LICENSE IS IN FULL FORCE AND EFFECT. �LIC. N0. �' �� LICENSE CLAS $ / DATE�� CONT ACTOR T_, WORKERS'COMPENSATION DECLARATION i �I HEREBY AFFIRM VNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE 'OFT i WHICH THIS PERMIT IS ISSUED. 1 �I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS �ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: I CARRIER �POLICY NUMBER��CA-0 I 33 (THIS SECTION NEH)NOT BE ODMPLEFED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS(ft(p)OR LESS). 1 I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I }SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE'NORKERS'COMPENSATION PROVISIONS OF SECTION 37D0 OF THE LABOR �CODE,SHALL ORTHWITH COMPLY WITH THOSE PRO IONS. � DATE: �AafiM J �WARNING: FAILURE 0 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE J SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINER UP TO ONE HUNDRED THOUSAND DOLLARS(f 100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION 3708 OF THE LAElOR CODE,INTEREST,AND ATTORNEY'S FEES. �CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY -FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CI V.C.). J - LENDER'S NAME LENDER'S ADDRESS C I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT U T AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING L CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE �ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. J � Q n 5 LIRE F PERMITTEE DATE L WHITE-Depanment Copy,YELLOW-Finance Copy, Plrvlc-assessor L,opy,L�v�v�rvnvu-r��e, ��Hy,�r,«�,