HomeMy WebLinkAbout14420 ��_ CITY QF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
w 22t�0E.CopleyDriveSuitet90 PRESS
�`'��^`��� BUILDING PERMIT APPLICATION FIRMLY
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.� STATENENi TilAT NE OR SHE iS tiCENSE�PURSUM1NT TO THE PROVISiDNS OF THE C�N7ftACTQRS Li�
� CENSE LAW(CHAPTER B(" MENCINO Wi?H SECTION lOpO�OF pIVISION a pF 7HE BVSME55 AN�PRO- � PDOUSpO
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��'. WILL C70 THE WORIC,ANL1'THE STRUC7URE I$NOT IN7ENOED OR OFFF.REo FOR SALE(SEC.�044,BUSI- J
� NES$AND PROFESSIONS CODE:THE COF�TFACTOflS LlCENSE lAW DOES NOT Aop�y 70 AN OWNER QF �
PR7PERTYN'NOBUNASORRAPR�VESTNEiiE4Ft.ANDN4i4DOESSUCNWORKHiMSEIFOfiHERS£IFOR m
C[ 7lIROLIOM HIS OR NEROWN EMPLOVEES,GROVIDEp THAT SUCH IMPROVEMENTSA%E NOT INTENDED OFl
i.}J OFFEfl€DfORSl�L.E.tf.l1QWEY£RIHEBUILDIN¢ORIMPROVEMEM1SSOlOW1THIN4NEYEAHOFCAMP4.E�
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= IMPFqVE FOR THE PURPOSE OF SALE). ..__
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� TO C4NSTRUCT 7HE PflC1JEC7(gEG.70�1,6USINE55 ANp PROFFSSIGryS CGD[:THE COPdTflAC70fl5 LI� V21UetlOfl ._ADJ,AREA__„^.,
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AIY LICENSE I5 7N FULL F6QCE AND 6FFECT
� UCENSE CLASS_L f___.___ �i%.r�o.__L.;—�`'� ,
V DATE �'�—"..��.—�__�__--- CONTRACTOR _
� WORKERS'COMPEPJSA710N DE�ATION � � � ��Q��}�'� ..
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QF TNE WYJFlK f(?R'XWrMTH�S PERMIT ISlSSVED. ��
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� I CERiIFY 7NAT IN 7HE PEWFORMANGE OF THF WtiRK FOR WHIf.H THIS PERI:A1715�5SUE6,1 MECHANICAL _ ,
{,� SHALL NQS E45PlOY ANY PERS()N IN AMY MANNEP SOAS TO BECAMG SUBJECTTtl j}1E ((�SP��TIC}N FEE �.,
� W(}RKERS'GOi3PENSAT'AN LAWS OF CAli�ORN�A.AND AC+REE THAT iF!SNpUtD BECOIA�'��� �-,�,���`,`�
� SUBJECTTOTHEWORKERS'COMPENSATIGNPAbVI51pNSOFSECTION3]OOOFTNEIABDR aSSUANCE __._ f
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� DATE: 1�""� t I _ APPLIGANT: � SMIP
J - � ENERGY P/C ,
� WAi7NING FA�LURF.TO SECURE WORMERS'CA G SATION COVERAGE IS UN4AWFUL,AND SHALL BE
� SV&IECTAN EMR.OYER TO CR�MiNAi.PENAlT S �CiVil f WES UP TOONE NUNOREQ iNOUS0.NQ ENERGY PERMIT _ ..,,__�
OOL.LAHS(F100.00tlI.��OIilON�O?NECOST FCOMPENSATION,DAMAGE9ASPflONDEOFOR�N �"'�'��—%r���
J SECTION310eOFTHELA90RCODE.INTEREST,ANqATTORNEV'SFEES. RETENTIONFEE: �� �`
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� 1 HEREBV AFfiFM 4YJDER PENAL7V OF P£RJURY THAi TH[f7E IS ACONSTRVC'ION LENOIN6 AGENCY
FOR THE PEFFOFMANCE OF THE WORK FOR WHICH THIS PERM�T IS IS5UE0(SEC.3091,CIV.C.). �
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4� LENDEH'SADDqESS�__._...,, ----- ��� �}' r�+ �J"'��- /! �#f t7}—'y
� �CEPTIGYiHA71HAVEREADTHISAPpLiCATiOt3AN0STATETHhTTHEABOVEMFOftMATIONISCQRflECt. IQ�A�FEGJ � V � .�� �' / '/
W I AGqEE TO COMPLY WItH ALL 4'ITV ANO CdJNTV ORDINANCES ANO STATE LAWS RELATINQ TO BUILDING �
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WHITE-6epartment Cop/,YELLOW—Finance Copy,PINK—Assessor Copy,Ca41DENR66—Fiie Copy,GREEN—Appiica�Ys Copy
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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
ADDRESS�D
ADDRESS
APN LOT TRACT
OWNER,-.-L Z.0> /Vt�C'ST• 1'-2�-
ADDRE,SS 2c//rL
CITY G4/ILI/aT U fZIP TEL.
APPLICANT TEL.
CONTRACTOR A � C LJ # eift fit,
ADDRESS
CITY ZIP 3 C TEL.901 J'Q it
ARCFUENG/
DESIGNER
ADDRESS
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 FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA PERMRTO CONSTRUCT.ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY 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 LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
0 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION
WALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES 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,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).
D I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044. 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 TO THE CONTRAC.
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.0 FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPP€I,
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRCFESSIONS CO
MY LICENSE IS IN FULL FORCE AND EFFECT
r/
LICENSE CLASS C/
LIC
NO
DATE I L. 1 :1 -7 ! 1 CONTRACTOR
WORKERS'COMPENSATION DEC ATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,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 OF TIE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS FERMI IS„
ISSUED. MY WORKE
INSURANCE CARRIER AND POLICY NUMBER ARE:
S COMPENSATIION
R
CARRIER � iTl/VILZ L Ct'1
POLICY NUMBER(2- F E Q 4 xe2^ (
(THIS SFCTION NEED NOT BE COO.PLETLDOFTHE PERMT IS FOR ONE HUNDRED COLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME—*
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVIS
17-t
DATE:
APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'CO P SATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALT S D CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST F COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 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
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
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
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTION ED PROPERTY FOR INSPECTION PURPOSES.
77D C�
PERMITTEE E INT)
Q 2'I-{-ctn
SIGNATU OF ERMITTEE DATE
APPLICATION i )I E i %iGC PERMIT i : ft/<.<%fo/r
/"'-1 1 UtI NUMBERI,I L/vs
ISSUE'TYPE
DATE CONST.GROUP
ZONING
SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
CONSTUCTlON
LAN EVIEW
EL TRIC
UMBING
MECHANICAL
INSPECTlON FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
SQ. Ff.
FACTOR PSF
'2e '
PRE- L F E:.
TOTAL FEES(-,
PRESS
FIRMLY
ADJ.AREAIVALUATION
OCC
FEE
In
77
COMMENTS
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy