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Home My WebLink About10287 (5)r 0 C> O 0 LLJs O a LL) Yn S2 cc O im W U O Z N W L¢lZ� 2W2 C) O LL Z O X� W rO U w a Nn iZ 6 a W Q CJ In 0 N 5 O W lL w O d W Q_ Z 9 m d On 4 CITY OF DIAMOND BAR • 'w COMMUNITY DEVELOPMENT DEPARTMENT 21660 E- Copley Drive Suite 190 l/ (909) 860-3195 Fax (909) 861-3117 'may �- BUILDING PERMIT APPLICATION JOBSITE ADDRESS Z'-' I APN LOT � TRACT OWNER Mgn-fO C=V`i^7o A4 0. J4 ADDRESS d 4 o CITY iIPqCjY1 TEL APPLIC NT TEL CONTRACTOR''/r7LNCi�t%HG /� ADDRESS IC CITY ZIP TEL ARCFVENG1 DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEG 701.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH MQUIRESA PERMRTO CONSTRUCT.ALTER. IMPROVE, DEMOLISH, OR REPAIR ANY STFRIC- TURE PRIOR TO ITS ISSUANCE. ALSO REOUmES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGHED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (CHAPTER 0 (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 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (1500).), O LAS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 7044, BUSI. NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND 010 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 BUIDINGORIMPROVEMENT IS SOLD WITHIN ONE YEAR OF OOMPLE- TKON. THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SAL4 O 1. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U. CENSE LAW DOES NOT APPLY TO AN OWNER of APROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORIS) LICENSED PURSUANT TO THE CONTRAC, TORS LICENSE LAW.), O 1 AM EXEMPT LARDER SEC. B L P.C. FCRTHIS REASON DATE - OWNER LICENSED CONTRACTORS DELLA ION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER f (COMMENCING WITH SECTION ?ODD) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. UCENSE CLASS LIC. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MANTAN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 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 WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (TLS SECTION NEED NOT BE DDNI.ETED OFTTEPEI'M IS FORONE MUNoRFDOOLLARS (SIOD) ORLESSy I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON W 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 PROVISIONS OF SECTION 37000E THE LABOR CODE I SMALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE APPLICANT. WARNINO: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SMALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (1700.000), IN AMMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 0E THE LABOR CODE. INTEREST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY 1 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 (SEC. 3091. COV C.). LENDERS NAME LENDERS ADDRESS I CERTIFY THAT 1 HAVE IEA) THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTKOFL AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVEN.HENTIONED PROPERTY FOR INSPECTION PURPOSES. PFgMIT, wNAME (PRI(T) `�/ `� IGOF PE DAZE N PRESS FIRMLY DATE APPLICATION ( PERMIT;& (% P/C NUMBE O x ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSEDUSE 4L"'"7/3IAjC- NO. DWEL f NO. NO. .. UNITS b STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADI. AREA/VALUATION SFR/ADD/REM _ Garage/Carport , WPatio/Deck LL Poot/Spa. . ZRe -Roof , 0 Commercial m Valuation ADJ.AREA OUANTITY DESCRIPTION FEE 0 2 morvv 0- a CONSTRUCTION PLAN REVIEW EL� UMBIN 4 70 MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY PIC ENERGY PERMIT RETENTION FEE PRE -ALT FEE TOTAL FEES 1 ITO COMMENTS 11 At A RECPT. PAID BY V4LIDATI WHITE --Dep rtmenl Copy. YELLOW—Finance Copy, PINK—A33OSSGF Copy. 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