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Home My WebLink About15059 (20)UI>11IIINU'11,11.1 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 ^^ /� ADDRGAESSS;4! 3; KY �' �� i APN LOT TRACT OWN ERn► i� <. l�A- ADDR S o=ff CITY W ZIP-12-1,Ii TEL &�—Oo APPLICANT.P r4 -0j --Q TEL CONTRACTQR*�L*-& 0 �� ►u AC ADDRES ry ,J CITY CITYL ___ f``�._ ZIP TEL.g It Y ARCFVENG/ DESIGNER ADDRES CI ZIP TEL. -- OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U - CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRESAPERMITTO CONSTRUCT,ALTEn, IMPROVE, DEMOLISH,OR REPAIRANYSTRUC- 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 0 (COMMENCING WITH SECTION 7") OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).): O I, ASOWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILLDO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, EUS - NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IR HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). d I. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7014, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LF CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTSFOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). O I AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON DATE _ OWNER LICENSED CONTRACTORS DECLARATION I HERERYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER ENCINO WITH SECTKN. 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND IC EIS IN FULL FORCE AND EFFECT, ry U EN CLABS-S �e LIG. NO. ` CONTRACTOR WORKERS' COMPENSATION DECLARATION IHER YAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS —1 VE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' PENSATION, AS PROVIDED BY SECTION 37000FTHE LABOR CODE, FOR THE PERFORMANCE O THE WORK FOR WHICH THIS PERMIT 15 ISSUED. I AVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSAT( INSURANCE CARRIER AND POLICY NUMBER ARE ARRIER STA,t'L POLICYNUMEER 2 OHIS SECTION NEED NOTSE ONFLETEDCFTFEPERNIT IS FORCNEHUNOHEDDOLIAPS(5100)ORLESS). 1 CERTIFY THAT INTHE 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 WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SURJECTTO THE WORKERS'COMPENSAMON PROLyyr��SSS,ONS F SECTION 37DO OF THE LABOR CODE ITP COMPLY WITH TkiDSE3V1�5 5. DATE; APPLICANT � "-F WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SI 00,0W), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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. 3007, CIV. C.T. I LENDER'S NAME _, — LENDER'SADDRESS i CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IB CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ADOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. L '- A ID v N SIGNATURE OF PERMITTEE DATE WHITE—Department Copy, YELLOW --Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy PRESS FIRMLY APPLICATION PERMIT / P/C DATE `�" �� NUMBER 6 p ISSUE TYPE OCC DATE _ a12 CONST. GROUP ZONING SETBACKS FRONT RW LJ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑/ PROPOSED USE NO. DWEL. ¢ NO. t NO. UNITS I STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM Garage/Carport WPatio/Deck LL PooUSpa U Z Re -Roof Commercial ib Ge Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q 2 U LLI UJ 0 _ 9- _0- 0- W U -1 CONSTRUCTION PLAN REVIEW U ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE '�+,� %>:f -� w / .�` SMTP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY ��VALID�ATIII