HomeMy WebLinkAbout14902 (17)91.1 MOND Ii 11:
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
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OWNER
ADDRESS
CITY nE P CTEL. Z
APPLICANT TEL. crc—'f�b
CONTRACTOR
ADDRESS-
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS 1-1-
CIE
FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REMIRESA PERMtTT000NSTRUCT,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-
CENSE LAW (CHAPTER B (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 OFSECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SW)):
❑ 1, AS OWNER OFTHE 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 CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR 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 OFCOMPLE-
TION, 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 CONTRACTING WITH LICENSED CONTRACTORS
To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT T07HE CONTRAC-
TORS LICENSE LAW).
O 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY UCENSE IS IN FULL FORCE AND EFFECT.
LICENSE S LIC. NO.
DATE 14 CONTRACTOR _
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WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
-OF THE RK FOR WHICH THIS PERMIT IS ISSUED.
HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WOR® PENS6TION INSyRANC R ANDPOLINUMBER ARE:
CARRIER
POLICYNUMBER f„�A -3 `:f
- I(O
(rHISSECIIONNE®NOTBE COM'LEfEDOFiVIE PERMI T IS FORONE HU DREDD01. "MOD) ORLESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE
WORK S' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SU&IE TOT WORKERS'COMPENSATION VISIONS OF SECTION 37000E THE
C/O SHALL ORT :=
H COMPLY WITH TH E K)NS,
DATE: PPLICANT
WARNING: FAILURE O SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND
DOLLARS (5700,000)- IN Am"DON TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANC AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE EPRESENTATIV OF THIS COUNTY TO ENTER UPON THE
ABOVE4AENTKINED PROPPEERRiTY FOR INSPE ION PURPOSE
L!J• J
PERMITTEE
SIGNATURE OF PSAMITTEE E 11
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PRESS
FIRMLY
CATION tri
PERMIT
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DATE
NUMB R /
ISSUE�I
TYPE
OCC
DATEf4?2CONST.
GROUP
ZONING SETBACKS
FRONT
RW ❑
REAR
❑
SIDE(SIDE STREET
RW ❑
SIDE
❑
PROPOSED USE
NO. DWEL. NO.
NO.
UNITS ._ STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
WPatio/Deck
Pool/Spa
Z
Re -Roof
0
Commercial
5
m
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING PATIS
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MECHANICAL
INSPECTION FEE _
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ENERGY P/C
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ENERGY PERMIT
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENT
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RECPT NO. PAID BY
VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy