HomeMy WebLinkAbout16347 (20)1)IMIONU Ii.U:i
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
ADDRESS - 3393. ;a1U61V A4`06n L A4
APN LOT TRAC
OWNER
ADDRESS
CITY _ZIP TEL
APPLICANT TEL
CONTRACTOR
ADDRESS -JA
C ZIP �_4�TEL
ARCR ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LL
CENSE LAW FORTHE FOLLOWING REASON (SEC MIA BUS W ESS AND PROFESSIONS CODEANT CrIYOR
COUNTYYIHMREO &SAPEAWffTOCONSTAUCT.ALTER eMPROVE.DEMOUStORREPAIRANYSTRUC-
YURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE U LICENSED PURSUANT TO THE PROVISIONS OF THE ODNTRACTORS U -
CENSE LAW PUMA A I (COMMENCING WITH SECTION 70DO) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE 13 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
T10N.ANY VIOLATIONOF SECTION 7071.6 BY AN YAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACRAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
O t AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK AND THE STFUCTURE IS NOT NI MM OR OFFERED FOR SALE (SEC. 7044, BUSF
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OMNER OF
PROPERTY WHO BUILDS IM
DS opt THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HS OR HER OWN EMPLOYEES, PROVIDED THAT SIKH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF. HOWEVER THE BALDING OR IMPROVEMENT IS SOLD WITHNONE YEAR OFCOMPLE-
TON. THE OW NERSUIDER WILL HAVE THE BURDEN OF PROVING THAT NE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING HTR' LICENSED CONTRACTORS
TD CONSTRUCT THE PROJECT (SEG 7011. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI.
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS POR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAO-
TORS LICENSE LAW).
O 1 AM EXEMMUNDER SEQ B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (oOMMENCNG WITH SECTION 7000) Of DMSION S OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS IM FULL FORCEAND EFFECT. _
UCEN E CU LIC. I-
-DATE CONTRACT ,4i - ;A6n
WORKERS' COMPENSATION DECLARATION
I NEP.T9Y AFFIRM UNDER PENALTY OF PERJURY CNE OF THE FOLLOWING DECLARATIONS,
_I HAVE AND WALL MAINTAIN A CERTIFICATE OF CONSENT TD SELF-INwm FOR WORKEP5
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR WHICH THS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REOLRRED BY SECTION
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MYERS' COMPENSATION ',M ANCE CARRIER AND POLICY NUMBER ARE
VARIER _ �2
POLICYNUUBER __CULL,.)
M419MrroIWMNOTLteoMfLEMOFTVEPEACISFCRONEl M%EDMLARSWMORLEM
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THS 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 W'OR(ERS' COMPENSATCN PRONASIONS OF SECTION 3700 OF THE LABOR
CODE. I SWUL FORTHWITH COMPLY VAIN THOSE PROVISIONS.
r
I DATE APPLCAHT:
1 WARNING. FAILURETO SECURE WORKERM
S' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (St0D.Wn N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
i SECTU1,1970509THELARORCODE INTEREST. AND ATTORNEYS FEES.
1 CONSTRUCTION LENDING AGENCY
i s
I ORHEREBYTHE ERFOA UNDER PENALTY OF K FOR
THAT THERE M A CONSTRUCTION (SEQ LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHIUI THIS PERMIT IS ISSUED (SEQ SOLI, CIV QF
7
LENDERS NAME
LENDERS ADDRESS
J I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CORRECT.
1 ION AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AHO HEREBY AUTHORIZE REPRESENTATIVES OF THS COUNTY TO ENTER UPON THE
�
ABOVE-MENTIONED PROPERTY R PELT^EJN PURPOSES.
J '
PERMITTEE NAME (PR�
SIGNATURE OF PERMITTEE DA E
C
WHITE—Department Copy, YELLOW—Finance Copy, PINK—A3SeSSd L:Opy. LiVwLNMUL 116 L WY. UMMMrY nppRcarn 3 a P'Y
PRESS
FIRBJI LY
APPLICATION O
PERMIT (
/C
DATE
NUMBER
a?
ISSUE O
TYPE
OCC
DATE
CONST-
GROUP
ZONING SETBACKS
FRONT
RW
O
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
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NO. DWELL - O.
UNITS STORIES
BEDROOMS
DESCRIPTION SO, FT.
FACTOR PSF
ADJ. AREAIVAWAT10M
SFPJADD/REM
(n
Garage/Cawd
WPatio/Deck
U-
PooVSpa
Z
Re -Root
0
Commercial
m
Vaivaticn
ADJ.AREA
OUANTITY DESCRIPTION
FEE
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co
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4
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CONSTRUCTION
•
PLAN REVIEW
ELECTRIC - -
PLUMBING
MECHANICAL-
- ---
-INSPECTION FEE -----
APR
---------------
0 4 2001
-------------------
ISSUANCE
SMIP
49
ENERGY P/C
ENERGY PERMIT
-
J
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
1 ��
COMMENTS
RECPT. NO.NJI) BY
VALIDATION
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