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Home My WebLink About12973 (11)1. CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Scute 190 (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY JOBSITE - ADDRESS Z. Z 7 O if % APN LOT TRACT OWNER Pe I / ADDRESS CITY ro IP TEL O- / 3 APPLICANT TELQ09 6Z/�/�/ CONTRACTOR ADDRESS 3— ui T/P CITY Mo'w" ZIP_ />C> _ TEL Z GZ/- 16/ ARCKENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.6 BUSINESS AND PROFESSIONS CODE ANY CRY OR ML*MWHbMAEG LRESAPFAMrTTOCONSTRUCTALTERIMPROVEDEMOUSKOR REPAIRANY STRUM' 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 LAW (CHAPTER I (COMMENCING WITH SECTION TODD) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS D(EMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BYANYAPPUC& NT FOR A PERMIT SUBJECTS THE APPLICANT TO A CMLPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): L - - aLASOWN EROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. 704• BUSI- NESS AND PROFESSIONS CODE: THE OOWRACTORS UCENSE LAW DOES HOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND V440 DOES SUCH WORK HIMSELF OR HERS" OR THROUGH HS OR HER OWN EMPLOYEES- PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFFERED FOR N SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHINONE YEAR OFC MF1 E - TION. THE OWNEFLBUIDER WILL HAVE THE BURDEN OF MOVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} - O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROTECT (SEC 70A4, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS L4 CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHOODNTRACT9 FOR SUCH PROJECTS WRHACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC- TORS LICENSE LAW.} G I AM IDU MPT UNDER SEG B. Jt 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 s (COMMENCING NTH SECTION 7000) OF DIVISION 3 of THE BUSINESS AND PROFESSIONS CODE -AND S NAIL MY LICENSE IFLU LFORCE Atm EFFECT. a LICENSE CLASS C 3 9 - LIC. NO. ��2 6 > p LATE —3— 99 CONTRACTOR 's - C iti tq,1 WORKERS' COMPENSATION DECLARATION Its O 1 I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATON•AS PROVIDED BYSECTION 3700 OF THE LABOR CODE- FOUR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION NSURANCE, AS RECUIRED BY SECTION 3700 OF THE LABOR COCE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS . BEEF MY WOB/IeA� COMPS �� N7RANCE CARRIER AND POLICY NUMBER ARE: POLICY NUTABER /d — (r,MSECRONF£®NOTEEaAFLETEOCFTWPBWIS.FORONEHRDRED MIOD)ORLESS) 1 CERTIFY THAT N THE PERFORMANCE OF THE WORT( FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION ONS OF SEC/T/IOW 7T OF THE LABOR COOS, I SHALL FORTHWITH COMPLY NTH VLFP1. { /{ DATE: 7-3— 99 ",Az �jj�Yu'-si[/C�!/ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL- AND SHALL BE SUBJECT AN EMPLOYER TO CRUNAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (sloo.OWL N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR COOS INTEREST. ANDATTORNM 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 PERMIT IS ISSUED (SEG 3097, GV. C). LENDERS NAME LENDERSADDRESS 1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY NTH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULDINO CONSTRUCTIOK AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TD EWER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPQSES, PERMITTEE NAME (PRINT) SIGNATURE OF PERMITTEE DATE APPLICATION PERMIT P/C DATE NUMBER_ ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE rt� 0✓<- e, /-'o 0 NO. DWEL "; ' 1 NO. - 0., . , UNITS `" STORIES ,. BEDROOMS DESCRIPTION S0. FT. FACTOR PSF ADJ. AREAIVALUATION SFRIADDIREM U) Garaga'Carporl - - - - WPallo/Deck LL Poovspa ZRe -Root 460 � Commercial - m l ValUati. 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