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Home My WebLink About14895I uS r o O w CO CCO o� Z cc W LL s rL IS TP_ Cr l/ Z a C a 11111)HI\D IIIli 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 JOBSITE 2373 0 �yLGOA'3 Vir—w ADDRESS . APN LOT TRACT 3 (7-&-7'7 OWNER ��ICA' Aj1( ADDRESS o Go 3 CITY Pmpnvo ZIP TEL taw: 3 APPLICANT SF4Jf/ " Zit! T�f: TEL ,SyI—¢uA-.Pn� CONTRACT R U r O 1 C FrUe-44ay) ADDRES CITY rcot. 0 + IP E ARCFVENG/ DESIGNER S✓1 1 A((. ADDRESS Id( DLI CITY 4110.4121,4- — Z TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS LL CENSE UW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSNESSAND PROFESSIONS CODEANYCITYOR COUNTY VMIM REOUAES A PETRMrTTO CONSTRUCT•ALTER. IMPROVE, DEMOUSH.OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REOUTAES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSEE) PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LN CENSE UW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PAN FESSIDNS CODE) OR THATHE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION TMIA BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500).F O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. "LL DO THE WORK AND THE STRUCTURE IS MOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTY VOID BULDS OR IMPROVES THEREON• AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR THROUGH Me OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFFERED FOR SALE IF, HOWEVER THE BUMMING OR IMPROVEMENT SSOLD WITHINCNEYEAR OF COMPLE- TION. THE OWNERBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} 0 L AS OWNER OF THE PROPERTY, AM EXCLUS WMY CONTRACTING WITH LICENSED CONTRACTORS TD CONSTRUCT THE PRCUECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. CENSE UW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND YMOCONTRACTS FOR SUCH PRMC. OJECTS WITHACONTCTOR(S) LICENSED PURSUANT TO THE OOTTRA TORS LICENSE LAW } O IMI EXEMPT LARDER SEG S. S P.C. F6R THIS REASON DATE OWNER t UCENSEDCONTRACTORS DECLARATION I HEREBYAFFRRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 0 IN (COMMENCG WITH SECTION 70111 OF DMSION 3 O ME BUSINESS AND PROFESSIONS CODE, AND MY LICENSE S N FULL FOVO AND EFFECT. 2 LICENSE�LJLS LIC, NO. V .DATE IJ� -•- CONTRACTOR 0 WORKERS' COMPENSATION DECLARATTO T1�E/�FBY AFFIRM UNDER PENALTY OF PERAIRY ONE OF THE FOLLO`MNGD RATIONS: .HAVEAND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFdN RE FO�- COMPENSATION. AS PROVIDED By RFCTON 3700 OF THE LABOR COD . OFTHEWORKFORWN"7' .AIT S ISSUED. -#HAVE AND WILL MAN,/ CORKERS COMPENSATION INSURAN ,AS RECUIREO BY SECTION 37000E THE LABOR CODs. FOR THE PERFORMANCE WTHE WOR( FOR WH ICHTHISPERMITIS ' ISSUED. MY YORK MDEN ATION NSURM CARRIER MID aIICY NUMBERARE / CARRIER U POLICY NUMBER (DGFECIONNE®NOTSE Oa pLLliD OF PERMIT IS FOR ONEIAA-Di EDtSHOLILD ,ODloa 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PSUED, I SHALL NOT EMPLOY ANY PERSCN N ANY MMWIER SO AS TO BECOME SUHE WOAKERS COMPENSATION LAWS OF CALIFORNIA AND AOREE THAT IF I COME SUBJECT70 THE WORKERS• COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE. I SHALL FOHTHW TH COMPLY WITH THOSE PROVISIONS. GATE: - APPLICANT. WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMNAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (9100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3703 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR 7W PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.). LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. (AGREE TO COMPLY VATH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CgUNr Y TO ENTER UPON THE ABOVE.MENTENED PROPERTY FOR INSPECTION PURPOSES. QjtMrrTEENAMEE(P (PONT), Ilf�L74 d --?'6V ITU OFP -TTEE GATE PRESS FIRMLY APPLICATION PERMIT -3B DATE 9- 3 - 9 � W.PiC NUMBERx _V ISSUETYPE OCC DATE s/ _CONST._ GROUP ZONING SETBACKS - • ' FRONT- �- - RW ❑ REAR - ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE r NO. DWEL NO. NO. UNITS / STORIES 2 BEDROOMS G DESCRIPTION SO. FT., FACTOR PSF ADJ. AREAIVALUATION SFR(ADD/REM U) Garage/Carport WPatlo/Deck PDOI/Spa LL 0 Z RG -Roof C) Commercial - - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE a I U - ILL- W _ r 1% FIR t - z. M 51 CITY B u. - - - 0 Lu 1' UCT - -- . ,1VI :PN ��.. ,. MBING , - MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGYF ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—FLnanoe Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—ApplicanCs Copy I