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Home My WebLink About15028 (17)CITY OF DIAMOND BAR -� DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 BU) 860-3195 Fax (909) 861-3117 PRESS ILDING PERMIT APPLICATION 1_:�-oD FIRMLY ,,. JOBSITE ADDRESS APNLOT TRACT ��s- OWNER i�eA/siN+rl L4 wi•� s0AU ADDRESS 7L�/ aI CITY L • ZIP TEL.720,53 APPLICANT CONTRACTOR ADDRESS CIN ZIP TEL I/ENG/ st / DES� DESIGNER /�� ADDRES CITY V1 ZIP IgQ,4, TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE ro LowNQ REASON (SEG 70.71.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMITTOCONSTRUC . ALTER IMPROVE. DEMOUSH, OR REPAIR ANY STAUC. TORE, PRIOR TO ITS ISSUANCE. ALSO REWIRES 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 5 (COMMENCING WITH SECTION TWO) OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE) OR TUT HE ORSHE IS EXEMPT THEREFROM AND THE BASIS FORTHE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPUCANT FOR A PERMIT SUBJECTS THE APPUCANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5508).): CLASOMEROFTHEPROPERTY,OR MY EMPLOYEES WITH WAGESASTHEIn SOLE COMPENSATION, TWLL 00 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 BULDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH W PROVDMENTSARE NOT INTENDED On OFFERED FOR SALEIF. HOWEVER THE BUILDING OR WPROVEMEM IS SOD WITHIN ONE YFJJIOF COMPILE THON, THE OWNERMUIDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE OIO NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} O LAS 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 OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHDCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(5) LICENSED PURSUANTTO THE CONTRA6 TORSUCEHSELAW) 01 AM EXEMPT UNDER SEG B. S P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY Of PEAUUP Y THAT I AM LICENSED UNDER PAOVISgNS OF CHAPTER f (COMWNCNO WITH SECTION 7000) OF DIVISION! 3OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE ISN FUL(L�FORCrrErrAND EFFECT. LICENSE CRASS P.L LIC. NO. 3 ,` ��pf DATE s�3 r_ pt> CONTRACTOR_CA4AfEW- r WORKERS'COMPENSATION DECLARATIO I HEREBY AFFIRM UNDER PENALTY OF PERANRY ONE OF THE FOLLOW WG CLARATION _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEL INSUREFORWORKRS' COMPENSATION, AS PROMOM BY SECTION 3700 OFTHE LABOR E,FORTHEPERFCRMANCE OFTHE WORK FOR WHK?ITHIS PERMIT IS ISSUED. 1 HAVE AND WILL MANTAN WORKERS OOMPENSATKN INSUnANCE, AS REQUIRED BY SECTION 7700 OF THE LABOR CODE, FOA THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MI WORKERS- COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POUCYNUMEER I 57 (THISSECTYIN NEED NOTBE amPLETEDOFTE PERMITIS FOR ONE1ElDRDDOLIARSI$ I I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FORW14 THIS PERMIT SSUED.I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SOAS TO BECOME SUBJECT OTHE WORKERS'COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHIM BECOME SUBJECT70TIE WORKERS COMPENSATION PROVIS)OSOF SECTION 3700 THE LABOR CODE. I SHALL FORTHWITH COMPL OSEPRONSI S. DATE: rrSH�APPLICANT WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL B SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SI00,000), IN ADDITION TO THE CAST CF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY 1 NEWBY 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. 3N7. CIV. C.). LENDERS NAME LENDERSADDRESS 1 CERTIFY TUT 1 HAVE READ T THIS APPLICATION AND STATE UT THE ABOVE INFORMATION IS CORRECT. (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-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERM( NAME(PRINT) SIONATU FPERMITTEE 1.DATE APPLICATION 1 a� 01 DATE NERmrr UMB R _211pco(i ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR 11 ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADO(REM Garage/Carport WPatio/Dock LL Pool/Spa 0 Z Ro-Root QCommercial m Valuation ADJ.AREA OUANTITY bESCRIPTION FEE U U W W 0 Ca (L Z a CONS UC,JTTIII N D `P f •[ \ �� • e� \E .CT I �J `FtLUMBING .fa MEC (CAL " y,, L1t PECTION FEE _-0-5. ISSUANCE �� VIM 07) SMTP ENERGY P/C F...T.K _—CTIA— j k3F n� Fi '%l L ` • �.,r,.+.Y ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: % T r L TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE --Department Copy. YELLOW—Finance Copy, PINK—Assessor Copy. GOLDENROD—File Copy. GREEN—Applicant's Copy