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Home My WebLink About15044UI:lAilti 1116~(. ii CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY do DEVELOPMENT SERVICES 21660 E. Copley thive Suite 190 .(904)860-3195 Fax(909)861-3117 BUII.DING PERMIT APPLICATION MM PERMIT N I jr,sr ADDjossRESS !Q 7�/�TIfPC/L ZONING SETBACKS FRONT REAR SIDEISIDE STREET SIDE RW RW x--- ❑ ❑ O ❑ APN LOT TRACT NO. BEDROOMS OWNER ADDRESS FACTOR PSF CITY ZIP TEL: APPLICANT TEL;______ CONTRACTOR .� fill C A� ADDRESS - Garage/Carport CITY - t' ZIP TEL: ARCWENG/ DESIGNER ADDRESS n CITY ZIP TEL. POCUSps e ZR@ OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LN CENSE LAW FOLLOWING REASON (SEC. MIA BUSINESS AND PIOFES CODE: ANY. TYOR Commercial STRUC- COUNTY ICH REO E, AITTO EON IMPROVE, H.OR S - PRIOR T ITS ISSUANCE, REQUIRES THE APP, SUCH PERMIT TO FIE A TURF, ENT TO ITS 6SUANCE, ISO REQUIRES THE TO THE P FOR SUCH PERMR TO M TONED STATEMENT THAT HE OR SHE 6 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF 9 OF THE BUSINESS AND PRO- CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION DIVISION AND B FESSIONS CODE) K2THATHEOR SHE IS EXEMPT THEREFROM TEEBASISFOR THE FRO A THE APED ANTT- TION.ANY SUBJECTS THE APPLICANT TO OF SECTION7031ABYANYRED PENALTY OF DOLLARS ACME. PENM.WY OF NOT MORE FIVE HUMORED DOLIARffi (i DL OWNER �THE PER WAG GS SOLE RMV EMPNOT SEC."COMPENSATION, THEAS THE STRUCTURE INTEES NDED O OFFERED FOR WILL OD THE WORK AND THE STRUCTURE 6 NOT INTENDED OR OFFERED FOR BALE (SEC. 7054. BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES HOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND W140 DOES SUCH WORK HIMSELF OR HERSELF OR Valuation THROUGH HIS OR HER OWN S APLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE IF, HOWEYER,THE BUILDING OR IMPROVEMENT 10 SOLD WITHIN ONEYEAROF OOMPLE- TION, THE OWNER -BUILDER WILL INYE THE BURDEN OF PFKMNG THAT HE OR SHE DRi NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). D L AS OWNER OFTHE PROPERTY. AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS WO CONSTRUCT THE PROJECT ISEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW OOEB NOTAPPLYTO AN OWNER OF A PROPERTY WHO B1M.D$ OR IMPROVES THEREON. AND BARD OONTRACfSFOR SUCH PROJECTS WITHAOONTRACTOR(S) LICENSED PURSUANT TO THE OONTRAP TORS LICENSE LAW.} 01 AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON �. DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER P (OOMMENCINO AVITH SECTION YMM OF OM ION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE 6 BI FULL FORCE AND EFFECT. �r,� ///� 7101 'K(�',�' LK:ENSE CLASS �/` LIC. NO. .. .. DATE �^ `'_=s��J CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS I HAVE NO WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATON.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 REQUIRED BY SECTION 3700 OFTHE LABOR CODE WR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERWT 15 ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE .,. CARRIER -T`� POLICY NUMBER _i_12� IC'ZL�--�� GT'C)CJ MIS SECTION NEED NOT BE00M PUITEDOFTIE PEWJ/T6 FOR ONE HUNDRED DOLLARS (SIM)ORLESSJ 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I ( SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE (p WORKERS'COMPENSATION LAWS OF CALIFORNIA, ANP AGREE THAT IF I SHOULD BECOME SUBJECTTO THE WORKERS'OOMPENSATKIN PROMS SOF SECTION 37000E THE LABOR CODE. I SHALL F,OFrrHWITH COMPLY WI EP ISgN4. p DATE: / ""�'L' APPLICANT. - j WARNING: FAILURE TO SECURE WORKERS ENSATDNN COVERAGE IS UNLAWFUL. AND SHALL BE ry SUBJECT AN EMPLOYER TO CRIMINAL PEKES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S1 W.0M), N ADDITION TO TNE.COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 6 A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 6SUED (SEC. 3057, CIV C.). LENDERS NAME LENDERSADORESS 1= TOTAL FEES COMMENTS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 6 CORRECT. d t AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, ANDHEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVEM ED PROPERTY FOR INSPECTION PURPOSES, PE E IPRI �1 r C0 SIGNATOR F PE 1 DATE PRESS FIRMLY APPLICATION DATE &I LOD ISSUETYPE DATE fx/CONST. PERMIT N I P/C 0 OCC GROUP ZONING SETBACKS FRONT REAR SIDEISIDE STREET SIDE RW RW x--- ❑ ❑ O ❑ PROPOSED USE NO. DWEL. NO. UNITSSTORIES NO. BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFA/ADD/REM Garage/Carport PetiWDBck POCUSps ZR@ -Rod Commercial - co Valuation ADJ.AREA QUANTITY DESCRIPTION FEE W �. Z sU[ T CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEEbF— ISSUANCE SMIP ENERGY P/C ENERGY PERMIT Ci RETENTION FEE: PRE -ALT FEE: AND 51J TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Co;* YELLOW—Finanw Copy, PINK—ABessw Copy, GOLDENROD—FIM Copy, GREEN--Applicanes Copy v