HomeMy WebLinkAbout15160 (20)C ^ 1 CITY OF DIAMOND BAR 1
-�— DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATIONJOBS
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ADDRESS 14 1- C 0"/ Cf
APN LOT TRACT
OWNER /tail C14A-o t _
ADDRESS J731 o L o r✓ . 7 ✓-1
CITY IP TEL
APPUCANT TEL
CONTRACTOR /
ADDRESS 44 A ••e 4-1
CITY . ZIP ' TEL
ARCKIENGJ
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFI M UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LH
CENSE LAW FOR THEFOLLOWNG REASON (SEG 7031.6 "NESS AND PROFESSIONS CODE ANY CIT•OR
COLNTY VA4M REMWSA PERMRTO CONSTM=,ALTER MPROVE.DEMOUSH OR REPAIR ANY STRUG
TURF PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE CR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS M
CENSE UW (CHAPTER a (COMMENCNO WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE ON SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION IMI .6
BY ANY
APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HNDRED DOLLARS (1600).3:
OL AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL 00 THE WOK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". BUSI-
NESS AND PROFESSKNS COOS THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY W40
BULBOR IMPROVES THEREON. AND WWIO DOES SUCH WORK HIMSELF OR HERSELF OR
W I
TXJ04 HIS OR HER= EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVEFt THE BVEDNOOR IMPROVEMENT 19 SOLDYRTON ONE YEAROFC O MPLE
' TICK THE OWNER6ULDER WALL HAVE THE BURDEN OF PAOVNG THAT HE OR SHE DD NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEI,
O LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LE
CENSE UW DOES NOT APPLY TO All OWNER OFA PROPERTY W40 BUILDS OR IMPROVES THEREON. AND
WHOCOHTRACTS FOR SUCH PROTECTS WITH ACONTRACTOR IS) LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.).
O IAM EXEMPT UNDER SEG B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
IHEREBY AFFIRM UNDER PENALTY OF PEFLXMTHAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (C01a1ENCN0 WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE ISN FILL FCACE AND EFFEC
7NO.
LICENSE CLASS L-' At LIC. NO.VDIATION DATE CONTRAWORKERS' COMPENSATIO
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFMNSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 5700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT U ISSUED.
_I HAYS AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE. AS REOUIRED BY SECTION
5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THG WORK FOR WHICH TMS PERMIT IS
ISSUED. MY WORKERS' COMPENSA,TIDN INSU= AND POLICY NUMBER ARE
CARRIER
POLICY NUMBER
(RHS SECTION NEMNOT BfCJMF1 IDOFTE PERMIT FORONEHNDFITI LIARS 01MORLES%
I CERTIFYTHAT IN THE PERFORMANCE Of THE WORK Fdi WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUWECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SIMECT TO THE WORKERS COMPENSATION PROVISIONS OF SECTION 37W OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICAR:
WARNING: FAILURE TO SECURE YORKERS COMPENSATKN COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (II00.0WL N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
SECTON370L OF THE LABOR COOS. INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
i
1 HERL'BV AFFIRM UNDER PENALTY OF PEILAIRY THA7 THERE H A OONSTRl1CTKN LLTNDNO AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3007. CN. C.).
f
LENDERS NAME
LENDER'S ADDRESS
I 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 13 CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COLNTY 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.
3
�ENYE (PROM
SO PE TREE DATE
PRESS
FIRMLY
APPLICATION�(1 PERMIT / �0 P/C
DATE 1 V� NUMBER >f
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE'S
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NO. DWEL NO. NO.
UNITS STORIES ' ' BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFRIADDMEM
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ENERGY PIC
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RETENTION FEE: rT-Tzn Nl(-)NDi3M1tt
PRE -ALT FEE: I'`-IL�Twtn ATt ,IQAT,7FTY
TOTAL FEES
COMMENTS
RECPT. NO. PAID BY VALIDATION
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