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Home My WebLink About16966 (10) CITY OF DIAMOND BAR EXPIRED � �, DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I 21825 E.Copley Drive MAY 0 9 2003 (909)860-3195 Faac(909)861-3117 PRESS -.:� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE '�� /��"Qq�y APPLICATION � �(�- l�' PERMIT I �"��, P/C o ADDRESS� �4�� DATE NUMBER' # � ISSUE � y TYPE OCC APN Q U�T_____ TRACT DATE I � 1 CONST. GROUP p OWNER � � � ADDRESS � ��'7'7J ZONING SETBACKS oCITY !// � ZIP / EL__.__ __ FRONT RW ❑ APPLI A.�' TEL. REAR ❑ o — SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR � � SIDE ❑ � ADDRESS PROPOSED USE � CITY �_ 21P TEL. w ARCH/ENG/ �'��r,,�� z DESIGNER�,��_��c-v�GG�� NO.DWEL. NO. NO. a A�DRESS UNITS STORIES BEDROOMS � CITY f�� ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-6UILDER DECLARATION SFR/ADD/REM O � I HEREBV AFFIRM UNOER PENALTV OF GERJURV THAT�AM EXEMPT FROM THE CONTRACTOflS LI� ('jgf0J0/C2fPOR W CENSELAWFORTHEFOLLOWINGREASON(SEC.]03156USINESSANOPROFESSIONSCODE:ANYdTYOR (n C� COUNTVWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOIISH,OFREPAIRPNVSTRUC� W Patio/Deck Z TURE,PRIOR TO ITS ISSUAIICE,ALSO RE�UIRES THE APPIICANT FOR SUCH PERMIT TO FlLE A SIGNED w w STATEMENT THAT HE OR SME IS LICENSEO PIJRSUANT TO THE PROVISIONS OF TI{E CONTRACTORS ll� � CENSE lAW(CHAPTER 9(COMMENCING WITH SECTION]000)OF DIVISION 30F THE BUSINESS AND PRO� � PooUSpa OFESSIONSCODE)ORTHAThEOR5MEI5EXEMPTTHEREFROMANDTHEBA515FORTHEALLEGEDEXEMP� � � U TION.ANYVIOUTIONOFSE��TION7D31.SBVANVAPPLICANTFOFAPEflMITSUBJECTSTMEAPPLIGANTTO Z RQ-R00� � A CIVIL 7ENALTV OF NOT MOFE THAN FNE HUNDRED DOLLAFS�f500�.): � fII,ASOWNEROFTHEPROPERN,ORMYEMPLOVEESWITHWAGE5A5THEIRSOLECOMPENSATION, � Corllme/Clel Z WILL DO THE WORN,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE i,SEC.706d,BU51- J NESSAND PPOFESSIONS O�DE:THE CONTRACTORS LICENSE LAW OOES NOT APPLV TO AN OWNER OF � PROPERTVWHOBUILDSORIMPROVESTHEREON,ANDVJHODOESSUCHWOfiKHIMSELFOFHERSELFOR � � THROUGH NIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH 1MPROVEMENTS ARE NOT INTENOED OR m W OFFEREDFORSlLLEIF,HOWEVER,hIEBUILDMGORIMPROVEMENTI550lDWITHINONEVEAROFCOMPLE � TION,THE OWNER-BUILDER WILL HAVE TME BUflDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR Z IMPROVEFORTHEPVRPOSEOFSALE). = 71,ASOWNEROFTHEPROPERTVAMEXCLUSIVELYGONTRACTINGWITHLICENSEDWNTRAGTOqS W � TO CONSTRUCT THE PR0.IF:CT(SEC.704d,BUSINESS AND PROFESSIONS CO�E THE CONTRACTOPS LI- V8IU8�1Of7 .....- ADJ.AREA W CENSEUWDOESNOTAPPIVTOANOY/NEROFAPROPERTVWHOBUILDSOPIMPROVESTHEREON,AND � �� - � �� = WHOCONTRACTSFORSUCHPFQIECTSWITHACONTFACTOR(S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TOHS LICENSE LAW). Y J /�Iy � ❑I AM EXEMPT UNDER SEC. B.8 PQ FOR iH15 REASON Q !//4�/ � � ., LL OATE OWNER F Z U W � LICENSED CONTRAGTORS DECLARATION W � I HERE9V AFFIRM UN�ER PI=NALTV OF PERJURV THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER � d 9�COMMENCINGWITHSEC�IONIOOOjOFDIVISION3OFTHE9lISWESSANDPROFESSIONSCODE.AN� Z X MV LICENSE IS IN FULL FORCE AND EFFECT m W n//� ' � LICENSE CLqS �1_[L.__ LIC.NO. "'L j F V �ATE ��__ CONTRACTOR a W ¢� WDRKERS'COMPENSATION DECLARATION � � Q � I HEREBV AFFIRM UNDER P=NALTV OF PERJURV ONE OF THE FOIIOWING OECLAflATIONS: U � Z Q O IHAVEAN�WILLMAINTAINACERTIFIGAIEOFCONSENTToSELF�INSUREFORWORKERS' _ COMPENSATION.A:i PROVIDED BV SECTION]7a00F THE LABOR CODE,FOR THE PERFORMANCE C.) ¢ �THE WORK FOR WNICH THIS VERMIT IS ISSl1ED. � � W I HAYEAND WILL M�1INTAIN WORKERS'CON�PENSATICN INSURANCE,AS REQUIRED BV S[CTION Q 37000F THE LABOR CODE,FOR THE PEFFORMANGE OF THE WOHK FOR WMICH THIS PERMIT IS ISSUED.MY WORKI=RS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBEH AFE: CONSTRUCTION J � CARRIER�/f ` _�._.__ PLAN REVIEW Z POLICY NUMBER_ ELECTRIC Q Q (iHI55ECipNNEmNDTBECOMPLEfmOFTHEPERNdTISFORON[HUN�f7ED00LW?fi(51oo�ORLESS). PLUMBING W Z I CERTIFV THAT IN'fHE PERFORMANCE OF THE WORK FOR WHICH iH15 PERMIT IS ISSUE�,I MECHANICAL � SHALLNOTEMPl.OYANVPERSON�.NANVMANNER50ASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONlAW50FCALIFOFNIA,ANDAGREETHATIFISHOUL�BECOME INSPECTIONFEE SUBJECTTOTHEYlORNERS'CAMGENSATIONPROVISIO'`y� � ECTION3�OOOF EUBOR t J � CO�E,1 HALLF ITHWITHCOMPLVWIIHTN ��t ISSUANGE ��/. � p DA7E: � � APPLICANT: SMIP _....__ W ENERGY P/C J WARNIN :FAIWR TO SECURE WOflKERS'COMPENSATION COVERAGE IS UNL4WFUL,AND SHALL BE J SUBJECT AN EMPLOVERTO CRIMINAL PENALTIES AND CIVIL FWES UP TOONE HUN�RED THOUSAND � ENERGY PERMIT DOLLARS(f 1 ao.o00),IN AD'JITION TO THE COST Of COMPENSATION.DAMAGES AS PROVIDE�FOR IN � SECTION31080FTI1ELABOpCODE.INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: L'��J � GONSTAUCTION LENDING AGENGY PftE-ALT FEE: � IHEREBYAFFIRMUN�ERPENAITYOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCY . ._____ ___.__ � FOR THE VERFORMANCE OF THE WOFN FOR WHICH THIS PEflMiT IS ISSUED�SEC.309],CIV.C.�. Z w � LEN�FR'S NAME __. .. __ H LENDEP'SADDRESS__ __. ^ % � ¢ ICERTIFYTHATIHAVEREi\�THISAPPLICAT�ONANDSTATETHFTTHEABOVEMFORMATIONISCOFFECT. TOTAL FEES � �„��,/' � I AGFEE TO CnA1Pi V WITH ALL GTY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING �� CONSTRUCTION,ANDHEREBVAUTHORRERFPFFSFNTATNESOFTHISCOUNTVTOENTERUPONTHE Z ABOVE-MENTIONED PROPcRTV FOR INSPECTION PURPOSE COMMENTS � l t�L -- J � m PEflMITTEE NT � /�i � � 51 E � = RECPT.NQ M PAID BY VALIDATION ~ WHITE—De anment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanPs Co P PY, PY, PY� PY� PP PY 9. �i i�i . �I � d: ; ` �� I i . _ . . . . . � . 1�'., @��'", . ��`, ��i�, ��'�. � � a�� ---- a � � � � , , _ �3�� :� � �, _ , �� >> � � � � �� _ ; ff �� pd � ��,�r��.��.� . �r � . �E — .. ,�� e,; E7i �� _ _ �.�� ?", _ r�� s�� w.Q �. �� ar � ` �. €.. E : . .. . ... ... . . . . ... ..... . ........ .... .... .... ........ .. .. ... .. . .. . i � 04� „ �.��r . - 'r' CITY OP DIAMOND BAR � � E��R�Q DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES - 21660 E.Copley I?rive Suite t90 "' (904)860-3195 Faac(904)&61-3117 MAY 0 9 2003 PRESS � �'„�°'T BUII,DING PERMIT APPLICATION FIRMLY y JOBSITE � �`� APPLICATION �/ PERMIT �'1 1 P/C o ADDftESS I 4%� ��'� �;�� .�T�ii �� DATE � � ti��.,� NUMBER � } � � DA EE TYPE DCC APN i.i�T TRACT GONST. GROUP p QWNER ��iAc�+�3� LC�'tSt�� ,{� � p ADDRESS� � � � ZONING SETBACK5 ��" CITY f r �i:. ZIP TEt. FRONT RW i�__,� APPF.ICANT � TEt. . REAR �— � _ SIDE/SIDE STREET RW ❑ � C4NTRACTQR(„(�}�J'SL�..ti� Y�'/~b_ I� 1}-><xi L�)(� SIDE L1--- ADDR�j S �I ;c�.�—�� ituC - �n"'f G�3�--� � CIl1`jl„�C;,�.l��J- ZIP„��TEL.i��Y' PROP4SED USE � ARCWENGf DESIGNER NO.pWEL. NO. NO. AODRESS rn UNITS STORIES SEDROOMS_ � CITY ZIP TEL. � � DESCRiPTiON Sp,FT. FAC70R PSF ADJ.AREANALUATIQN Q t7WNER-BUIIDER 4EGLAFiAT10N SFRtADl71FkEM � 1 HERE6Y AFFMqM UNf)ER PENAI,TV OF PERIUFlV THAT I AM EXEMVT FROM THE CONTRACTpRS l4 �g�age/C.•ef�Ort W CENSEUWFORTNEWllCWlNGfiEA90N(SEC.T031.SBU5INESSANOPPOFESSi6NSCODE:ANYCiTYOq (j� . �.� COUNTYWHICMHE<]UIRE9APERMITTOCONSTRUGT,ALTEq,IMPflpVE,DEMOUSH,ORqEPA1RANYSTRUC� W W TUFlE.ANtDfI TO ITS 4S511ANCE,�L50 REQUlRES'fHE APPIlGANT fOR SUGH PERMIT Tp��E A^u1GNE0 � Pa�I0/D6CK .�r STATEMfM THAT HE OR SHE IS LICENSED PURSUAN7 70 TNE PqoviSioNS 4F TME coNTRAGTOpS U. � CENSE UW(CHApTEF Y(COMMENCINO WI7N SECTION 7U00)OF DIVISIpN 9 t}f TH�BUSINE55 AND PRO� � POOUSpB FESSIUNSWQE�4RTHXfNEORSttEiSEXEMPTTNEFEfflOMANRTHEBASiSFORTHEAII£C.EOEXEMP• (� 'ipN.ANYVqUTq140F3E:CTION7091.58YANYAPP�ICANTFORAPERMITSU6JEC7STHEAPPLICANTTi7 Z RB-ROO} � A CMl PENN.TY OF NOTµ�pF 1HAN FNE HUNDRFO 0041AR5(#500).): � �'I,ASOWN£ROFTNE:PRQRER"CY,�FiMYEMPl6YEESWi"fNWaGESASTNEIiiSOtfCOMpEN5A7bN, � COtrim9tCidl YALL D4 TME WORK,ANp 1'HE$TRUC7URE IS NO7 INTENDED OR OFFEFED GOR SALE(SEC.�0�4,BUSI� J � NESS AtO PqOFE5S10NS GOpE:THE CONTRACTOqS UCCNSE LAW DOES NOT APPIV TO AN OWNER Of � PRDRER(Y WFiCS @UIL0.S 64i MPfiOVES THEflEOM,M'D WM4 DOES SUCH WiJflKtflM5ElF OFi HERSELF OR WTNROlIOMHISORHEROWNEMPLOYEES,PFQVIDEDTHATSUCNIMPflOVEM@NTSARENOTINTENOEDOR m p t�F£flEDf�tSKE.tF,HUWEYE11,iHEBU1lDINGQFi1MPfKlV9AENTiSSOLDWIThNNOfYEYEAflOfCAMP{,E- � TiDN,iHE OWNEp�OUiLiYE�WIU.HAVE THE 6URDEN OF PROVING THqT HE OR SNE D70 N07 BUtID RR W PFlOVE FOR THE PURP03E OF SALE). � [�t,,tStl4VNER6F'H=PROFERTY,AA4('XCttl3NELYGati7RACFiNCiWiTHIMENSEDS7JNTRAGTORS — � TO CONSTRUCT THE PROJECT(SEC.7041,BUSIN�SS ANQ PROFESSIONS CpOE:THE CONTMCTORS LI� VaIU8�I011 ADJ.AREA � CENS[UW[70E5NOTAPI�LYTppNqWNEROFAPROVERTVWNOPUttD50RIMPqOVESTHEREpN,AND -- —�--'—""i � WF#CONTflACTSGOtiSUL:NPFi6JECTSMifTNAtXaNTRAC'T4R{SjUCENSE�PIIRSU,iNTTOTHEC(')t1TRAG QUANTI�TY DESCRIPTIQN TORS IJCENSE UW.). FEE I � J Q (J 7 AM EXDdPT UNpfA SEC.! � _B.d P.C.FOR Tiil$flEA50N Q 3 U u" DATE � OWNEF F- "' z _ __. � � � - w LfCENSED CONTRACTORS DBCLARATION -� � w i HfRE$Y AFFIRN tk7DEfl k'ENAtT`f 6F PEFiJURY THAT{p,f,{�tCFNSED ttPpEA PR6VISI6N5 OF CtiAGTER � � 9�COMMENCINOWITMSE(:TION700o)OFDIVISIONJOFTNEBUEINESSANDPROFES510N5CqD6,AND Z �� MY LICENSE IS IN FULL FORGE M1�EfFEGT. m � IICENSE S �_,L�`� LIC.NO.��'�� WDATE_�Cy��,�yZ�.�,,,.,, CONTRACTOfj�,,,{��j,�O��,��_A' Q � � � # N/ORKERS'COMPENSA710N DECLARATION �i� Q �� i HEREBY AFFliN.i UNDEF PENAtTY OF PERIURY ONE OF TNE FOIIOWING DECLARATfONS: U �, � Z C1 _i NAV£ANp WILI NAIPI7diu A CEftTiFICA7E OF C6NSENT TO SEIFiNSUR£FOR WOQKERS' a �� L = � CX�MVEN9�TION,��5 FROVIDEO BY$ECTION 3l0o GrF?NE Ln80fl CIX�E,FOR THE PERFpFiMANCE U � OF TME WClRK FqR WHICH TNIS PEflM1T IS ISSULp. � — � __I HAVE ANp WILI,.IAAINTAIN WORKERS'COMPENSA710N INSURPNGE,PS HEqUIRE�BY SEGTION � d� 3T00 OF THE LA$[}A G�£,FOfi TttE AERK7RMkMCE OF TrfE}YbRK FOR WMGH TNIS PERMi715 � 159UE0.MY WORKERS'�MPENSATION INSURANCE CARRIEF AND pOLICY NUMBER ARE� CONSTRUCTION _ � s __ j cnaaiEn��;�'1 + 1/'�5'.(�� PIANREVIEW �_ —� � POI.ICYNUMOER r71iZ{ El.EcrR�C �-�� w��"�� __.-- ,� ,—.__..:— Q (1%pSSECIk7NNEEDPpT8ECt7Ri1F7F.DOFlS�"f'E%7rsFOFlon�6i�l1NIXiEOGqILwSfa�oo)Oalessl. PLUMBING � � � . . �� —.....—� W � 1 CERTIFI'THAT IN THE PERFbRMANCE OF THE WORN KOR WHICH TNIS PFtiM171S ISSUED,I MECHAN�CAI. __�_ ��—�—��+.�] � (;} SHAIINOT EMPLOY ANV PEfl$ON Y MANNER 50 AS TO 9ECOME Sl1BJECTi17 THE . � (J) WOFKfRS'cOMPENSATIOti tAWS O ALtFORNIA,ANU A EE TtiAT tF I SHOULR BECA{AE 1NSPEGTIQN FEE � SUWECT t0 TlIE WO%KERS'COMPEN TI4N PROVISION D SECI'ION 3�Uq OF 7HE 1P,90R � �' ♦ —_� coCrE, sHntLF nT�+wir�coM vwi 'n+osevRovis . ISSUANCE _,.____ . �'�J• I.,JQ O —.__ p DATE: yi APPLI � ' _..._....—. .� SMIP ._. ---�-----'"-,.- _ _._...__..r ...� _._ . w ENERGY P1C �` � - � "J WARNING:FA LURE T IcCUqE WORKERS'COMPENSATIK7N CqVERAGE IS UNLAWFUL,ANb SHALI BE --- _.! .-.......�..—_...._ ._ � SU&lECT AN EMf'LOYER TO CftIMUJAL PENAI,TIES AND qVll FlNES UP 700NE MUNORED Fl10USAND ENEfIGY PERM2T DOUARS(F700,W6).iN ADDiTKSN TU 7HE COS?OF COfaiP�NSATION,pAMAGGS AS PROviOEU FOP IN J SECTION 37080F THE I,A.BOR COOE INTERE57,ANU FTNPNEY'9 FEES. � RETEN110N FEE: OGONS7RUCTION LENpING AGENCY PR6ALT FEE: __ _ �� I HER£8Y AFFIRM UNDEfi PENAITY OF PERJURY THAT TtiE9E IS A GQNSTRUCTION i.EMDtNG AG6NCY FOq THE PERFO%MANGE:OF THE WORK FOR WHICH THIS PERMIT IS ISSUEp�SEC.908�,CIV.CJ. '-��---- — z tJ3 � LENI7ER'SNAME�v„ !,_�_ .i '— ..� —'--�"'" H- LENDER'SADDRESS__ _ w IGERTlFYTHAT4HAVEREADTHISAPPLtCAT�OM1iANRSTATETHATTHEA80VEWF�RMATpNiSCORRECT. TQ�HtF�EJ �,�� I AGREE Tp COMPLY WI1H ALI.CIN AND CPUNTY OR�INANCE&AND STATE IAWS 4iElATIMG TO 9UILOING � CONSTRIlCTION,ANO HI:REBY AUTMORtZE REPRESENTATNES GF THlS COUNi1'TO ENTEq UPON THE Z ABOVE-MENTYJNEO PFf)PEflTY FOR ItiSPECTpN PURPpSES. (",.OMMENTS � _ � ��'`__��=�ui,�._-.._ ------ -- m A EE NAA1E t��NT) Q '_ .,,� � � i �; r' ---- � SIGNATVq66FPERMiT"f£�'�"^-� pp� �`� ' �— �— 2 RECPT.NO. PAID BY �� „ % VALtDAT10N _ E WHI"fE—Ospartrnent Copy,YEtiOW—Finance PiNK—Assessw C CoDy. opy,GQIDENRQ6--File Copy,fiREEN—AppiicanYs Copy �g_ k� �"'�� $��'�� .�L' � ��s�� .�� " ��g�� '�', � # �: # d » � , _: , = f� �� '� hs � � �� _ _ _ ._. __ __ _ �� - �-r � � _ _ __ _ _ . _ _ - : 1 �ar �n 8 .,.. .... , .__ ' __ _... _ _ .. _...__ .__ . —.... — ..._. _ __� _ . �<, -.i fl, �.:�, . : ', .s `"`# 1 Y t'"s n a � . , : ,__ ._.. __. . _. .. ....... ..... . . ,;. • . .. __ ....._ ..._.. ._... _. ..._...... . .. .... .. . _. __� __. _' ___._.._ . ,,� : ��. .rr '�i'�s �r: , �.__ .� .. — ..._ .__ ..._.. .._. .. .. .. .. . . ...� ......_ ._.._ ._.. . ._.. .. .. .. ... . .... . ..._. .: ... . ...._. .. . . . .... ... ._ . a�.e �� €; -. . .. .... ......... .... .. . .. .. _.. . � � � . __ _— ... _.. . � ;�° � � �- _ .. ._. _. `e �-x .��hs... �,u��z.. .. ... . . . ._. ....._ ...... _.. .. ._... ...... ..._ __.. .. . . ... ... .... ._.._. .. .... .._... . ..... .. ..... .._. ._... .___ ..___... . . ....... _..... ..._. __ .. _.... ..... ....... .._.. ._.. _._.. .. .._ ..... . � ... ... .._. _ . .. _...._ . .. .. . ..._.. ......_.__. ...._._. .... .. . ..._. _..... .. ._....,. ._... ._... . ___ . ._...._..._ . �....... ._. . . _. ... . ._.. ...... ...._. ... .. .. ..._. .._ . ._.. ...._. ._... ._._. .__ ._... ___.. . _.._ .... . .. ... . ._.. ...... _._.. _...._ .... ... .... .. . ..... _.. . ...... _..... ._.. . .. . . ..... . .. .... ......_ _. .. . ._. .. .... " '' �' '�- a�a ��. ._ .. � .��3�:��,�'��e�'`� r��,� '� . _. .. _.. _ . ... . . .... .. . .. .. . _ .. r k , � ��'"�'��a� �^�� d��' _. _. .. . '� ��x �+ r ..-, _ _ ��.�'�zaa��`�. . � ��.�� .. ._ .. q {�€��„� .... .�. ._. ._.._. .. ... .__ ... ... _... ....... ..... _. ... .... . ... . � -� � �� '�,�;��i�T�°�t�� ,� �"��^�� :�� a' � � �;� _ �"�f�� ,� �� ^�+-��"�� _ �,id� ; ,a �,,� �� , � �`�� ;e �� k �. ;��f� �� ; � �I CITY OF DIAMOND BAR DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fact(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE'r ADDRESS_ APN c0 LOT TRACT OWNER� ADDRESS CITY !//�ZIP/EL. TEL. APPLI A CONTRACTOR ADDRES CITY� ZIP TEL. ARCH/ENG/ 7 UhLc-�� DESIGNER LJr/�� ADDRESS Tr CITY��ZIP TEL OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLO W LNG REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC- TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS II� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO- FESSIONSCODE)ORTHAT h E ORSHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f 5001.): 0 I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 706d, BUSI- NESS AND PROFESSIONS ODDS:THE CONTRACTORS LICENSE LAW GOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF,HOWEV ER,THE BUILDING OR IMPROVEMENT IS SOLD W(THIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE LAW DOES NOT APPI V TO AN OWNER OF A PROPERTY W HO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). ^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR iH15 REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECr10N 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND ND EFFECT_ MY LICENSE IS IN FULL FORCE A / " L NO LICENSE CLAS��/D LIC DATE ��CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,A:i PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKI.RS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (EHIS SECTION NEED NOT BE OOMPLETED OF THE PERMIT IS FOR ONE HUWRED DOLLARS(5100)OR LESS). I CERTIFY THAT IN'fHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE YIORKERS'COMPENSATION PROVISIOy� F ECTION 3]o00F E LABOR 0 CODE, 1 HALL F ITHWITH COMPLY WITH TH 1 APPLICANT: I/�' 1 DATE: I 1 WARNIN : FAIWR TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE 1 SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY HE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC. 309],CIV.C.). FOR THE PERFORMANCE OF T J LENDER'S NAME --Y� - LENDER'S ADDRESS --. I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE CONSTRUCTION ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSE PERMITTEE NT /^' 51ED 0 0 0 LL 0 w z a z m w 0 0 w 0 z w vi 0 W U Z W U Z LL Z 0 d X W 0 U W O Q Q 0 J I.L J a 0 W Z 1-- w d Z m WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Gopy,GOLDtNHOU-Hlle L:opy, L�Httrv-nppucanrs copy 2-3 CITY OF DIAMOND BAR� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY ADDRESS z,'�G�C1U ��i�/�L,fj�,'i'yy� �,��U APN LOT TRACT OWNER r��'�h �9r LLt./ ADDRESS� �� CITY�t�ii ZIP TEL. APPLICANT TEL. CONTRACTOR� � �'- �"A'-'.'Z .JCs S ADDR�� q��-�� JJ CITY(IA-ZIP��-6'-F$'TEL��t�'/ ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIFOA UNDER PENALTY OF PEFWRV THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLCWIiNG REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE:ANY CITY OR COUNTY WHICH REWIRES A PERMTTTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC- TURE,PRpR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSELAW(CHAPTER fl (COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT IlE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VKILATKXd OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT AMDRE THAN FIVE HUNDRED DOLLARS(1500).): ^ I,AS OWNER OF THE: PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATK)N, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70x4, BUSI- NESS AND PROFESSIONS(X)DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF PROPERTY WHO BUILDS Ofi IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THRWGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITN LICENSED CONTRACTORS TO CONSTRUCTTHE PROJECT(SEC. 70M, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI� CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TOTHE CONTRAC- TORS DCENSE LAW). 1 AM EXEMPT UNDER SEC._B.f P.C. FOR THIS REASON DATE OWNER_. LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTEq 9(COMMENCING WITH SECTKN1700o)OF DIVISKXA 30F THE BUSINESS AND PROFESSIONS CODE.AND MV LICENSE IS IN FULL FORCE AND EFFECT. c LICENSE C S� �+�'�LIC. N0. °��i �� DATE_�_CONTRACTOf��gy,p�f�-�'�" My� A NIORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL IAAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATION,+\S PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL IAAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS TKNJ INSURANCE CARRIER AND POLICY NUMBER ARE: PEN A ISSUED. MY WORKERS'COM S �� f CARRIER� �� L'm/'�I Z 7��5, J POLICY NUMBER�� J'� (T US SELTgN NEED NOT 8E Cf7MPIF-TmOF TFIE PEFV.9T IS FOR ONE IaIM�iED DOLLARS(f1TA)OR LESS). 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PERSON I Y MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COME ENSATION LAWS 0 ALIFORNIA,AND A EE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS'C:OMPEN TION PROVISION 0 SECTlON 3700 OF THE LABOR CODE,SHALL F RTHWITH COM V WI THOSE PROVISI S. I I DATE:j,E'�APPLIC�� _ I 1 I WARNING: FA LURE T I.=CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(f 100,000),IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN I SECTK)N 3708 OF THE LP.BOR CODE,INTEREST,AND ATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY i I HEREBY AFFIRM UNDEfI PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE: OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.CJ. 1 LENDER'S NAME LENDER'S ADDRESS �I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTlON,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE ABOVE-MENTKNIED PROPERTY FOR INSPECTION PURPOSES. Ii '�p,��i�� + it•' � ER EE NAME(PRINT) i �S�� DA� D SIGNATURE OF PERMIT�EE�- WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy