Loading...
HomeMy WebLinkAbout10826C/5 0 i� U MUNI IIAk r a CITY OF DIAMOND BAR . COMMUNITY DEVELOPMENT DEPARTMENT 21660 E. Copley Drive Suite 190 PRESS (909) 860-3195 Fax (909) 861-3117 '' BUILDING PERMIT APPLICATION FIRMLY JOBSITE ADDRESS Z APN LOT TRACT OWNER 3 f,%Ay" AD ESS V Z'1 CIN 1 IP TEL ' APPLICANT -TEL. CONTRACTOR ADD S � CITY ZIP TE Tlr"* -95_Z4 ARCH/ENG/ , DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION .. - I HEREBY AFFIRM UNDER PENALTY OF PEFWRY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC 7031.5 BUSWESSMND PROFESSIONS CODE: ANYCITY OR COUNTY WHICH REQUIRES APERMITTO CONSTRUCT,ALTER IMPROVE. DEMOUSK OR REPAIRANY STRUO TUBE. 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 LL CENSE UW (CHAPTER 0 (COMMENCING WITH SECTION TOGO) OF DIVISION i OF THE BUSINESS AND PRO- FESSIONS ROFESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031 F BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).)'- LAS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70", SUSI. NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO HE BUILDS OR IMPROVES TREON, 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 BULLDNG OR IMPROVEMENT IS SOLD WITHIN ONEYEAROF COMPlE- T10N. THE OWNER-a"DER WILL NAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). Q LAS OYMEROF THE OF AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC las, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LF CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILOS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTONS) LICENSED PURSUANTTO THE CONTRAC. TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC B. 5 P.C. FOR THIS REASON DATE OWNER - - LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSW ESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIG. NO. >SS DATE l 0--Q.� CONTRACTOR 0A'• WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS. I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WORKERS COMPENSATION, AS PROVIDED BY SECTION 37000E THE LABOR CODE. FOR THE PERFORMANCE �F OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. ,yam I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WOIj{K.E,.R�S',COMPENSATION INS INCE CARRIER AND POLICY NUMBERARE: CHARIER ,-,��eLn1� �`-^ POLICYNUMBER �`U-ql 0P0*7'ry gMSECTIONNEEDNOTSECDVA EDOFT7EPEWItSFDRONENLS4LRM170UARS(SIOMORLE5s1 I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON W ANY MANNER SO AS TO BECAME SUBJECT TO THE WORKERSCOMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37DO OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS DATE: APPLICANT. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNL WFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIM VIAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100.0001- W ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 37050F THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.-' - CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERL41T IS ISSUED (SEC. 3087. CIV C). LENDER'S NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS 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 ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. �` ,J Q,� ramal NAM P PERMIRI 10A, &:7t -, SIIGMCURE OF PERMITTEE �� APPLICATION /�Q ` PERMIT �© �R% P/C DATE ( NUMBER # ISSUE OFTYPE OCC: DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE 1 L ati NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADWREM -- - - U) Garage/Carport WPatio/Dea L- Poovspa 1� z ZNo-Roof i . Commercial m Valuatwn ADJ.AREA QUANTITY DESCRIPTION FEE J 6 U - cc W J W - 0 Z 01 OCT 0 6 07J EL Q U Z a S U - - W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL IN FEE j ISSUANCE C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES _ COMMENTS \ �� ''�k ( t vJ RECPT. N0. PAID BY VAUDATION WHITE—Department Copy. YELLOW—Finance Copy, PINK—Assess" COPY. LSUWLNHUU-1110 L.opy, UMLLN—APPI10ant 3 Wpy cc o Q I m C2 W� .nZ O O F LL U O W a U _ 1= .•r ^a c _ obi_ -. F- ❑ T J O ❑ z❑ Q 0co co W z0C7x¢wzQ�OCia z z V C7Cn lL Ui Z LL _❑ r • • O [J W LLL LL. CL. Zi U. 2 L)0ww m F z O O m Q m_= Z O Cry J W W LL z LL W F. F Q Z W Q U W zF=W O N CL W= ❑ � W W • lL p C o Z Z to Q¢ w xp m FF-- LL Q Z Lb Q z❑ W O x Z O O O O O O LL LL 0¢ W Z U z F_ U< Z Z ❑ W LL F- Q W LL j W C7 W - • - . J LL 2 LL PID LL LL w LL LL m m LL d m m O❑ LL QQ _i O LL LL x❑ Z W r � I z O L � • NO 2 co U=Z ZFZF'?F LU d C7 ¢ z fA Yfn. Y Cf)Cc LL C7 U J OL Wp ¢ W¢ W Q W W Z W Q W_ W J W J a co ❑ 2aJZ (` J ❑ (/7 Z Z J Z Q J J W- F y Z z Q F- W❑ lD W z F- F- U • ¢ O LL N.. LZ ❑ zC} W a p- �- W (n 1L Z O LL xxx 0. U� W F Z J ('J Z J ¢LrUa_ W F F F_ a Li Q 0 J 2 J W J LL J U d F• d' Fco L U❑ W Co w� LL O FX�- w w �U m LL LM to YL Q CL W Q W U w (.7 LL lL lL LL fn fn