HomeMy WebLinkAbout16347 (22)CITY OF DIAMOND BAR
'J DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860.3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBS
ADDRESS - 3393. t DM
APN LOT TRAC
OWNER
ADDRESS
CITY_ ZIP TEL 7 - - /
APPLICANT TEL
CONTRACTOR "'
ADDRESS v
CmQw2utmaZIP�TEL �`
ARCRUNG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LE
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CUOEANY CINOR
CONTYWHn4REn RESAPEAAUTTOCONSMX-T.ALTERIMPROVE.DEIJOLISLORREPADIANYSTFtLC-
TURF, PRIOR TO ITS ISSUANCE, ALSO RECUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS I.I.
CENSE LAW PUMA A I (COMMENCING WITH SECTION 70DO) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS
RO-
FESSIO NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
T10N.ANY VIOLATIONOF SECTION 7071.5 BY AMYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACRAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSO)).r
0 t AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFEn1O FOR SALE (SEC. 7044, BUSF
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UWN
W DOES NOT APPLY TO AN OWNER OF
PROPERTY WN, HO BUILDS OR IMPROVES THEREOAND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SIKH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDINGORIMPROVEMENTISSOLDWITMNONEYEAROFCOMPLE-
TDN. THE OWNERSUILDER 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. ATA EXCLUSIVELY CONTRACTING WTO' LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7011. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NNOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHOCONTRACT 3 POR SUCH PROJECTS WITH ACONTRACTORIS( LICENSED "WANT TOTHE CONTRAO
TORS LICENSE LAW► -
01 AM EXEMMUNDER SEC, B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION -
I HEREBY AFFIRM UNDER PENALTY OF PERKIRY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(�OAIMENCINGI SECTX)N 7000)OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS IM FULL FORCEANO EFFECT. _
UCEN E elA LIC. NO.-
-DATE 6 WA h. CONTRACTOINe,,"H;
WORKERS' COMPENSATION DECLARATION
I NEPI BY AFFIRM UNDER PENALTY OF PERJURY CNE OF THE FOLLOWING DECLARATION&
_I HAVE AND WALL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INwm FOR WORKERS•
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR VrNMH THS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORI(ERS COMPENSATION INSURANCE. AS REOUTRED BY SECTION
37000E THE LABOR COOS FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MYER5 COMPENSATION1,ySyPANCE CARRIER AND POLICY NUMBER APE
CARRIER _ ��
POLICYNUMBER _ -1--i_]
(}IISSECTIONMEMNOTpECMI+L>TEDOFTLEPERMITIS FORO NEHMDRDDMARS W MORUESn
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THS PERMIT IS ISSUED, I
I -- - ----- SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TD THE --- - -- -
j WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORI(ERS' COMPENSATCN PROVISIONS OF SECTION 3700 OF THE LABOR
COOS. I SHALL FORTHWITH COMPLY VAIN THOSE PROVISIONS.
I
DATE APPLICANT
1 WARNING. FAILURE 10 SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
M LIECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ISIOD.DOOL N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
i SECIT)M 9705 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
I CONSTRUCTION LENDING AGENCY
i s
I ORHEREBYTHE ERFO UNDER PENALTY OF K FORIWY THAT THERE M A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR NIUIUI THIS PERMIT IS ISSUED (SEG 3017, CIV GF
i
LENDERS NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. ANO HEREBY AUTHORIZE REPRESENTATIVES OF THS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY R PELT^KIJN PURPOSES.
3 PERMITTEE NAME (PRINT)
� SgNANRE OF PERMITTEE
DATE
PRESS
FIRBJI LY
APPLICATION O
PERMIT (
/C
DATENUMBERIt
ISSUEO
TYPE
OCC
DATE
CONST-
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
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NO. DWELL -'NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SQ, FT.
FACTOR PSF
ADJ. AREAIVAWAT10M
SFPJADD/REM
(n
Garega/Carport
WPatia/Deck
LL
POOVSPa
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Commercial
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QA
Vaivau
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION
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-INSPECTION FEE-- -----------------------------
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ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENTS
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VALIDATION
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