HomeMy WebLinkAbout15034U1.1!II►SU I1:11i
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. CopleyDdve Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
ADDRESS
APN LOT TRA T
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS O
CITY ZIP
ARC WENG/
DESIGNER�t�IWUSfCtcl.�7s_(�,tt�C
ADDRESS_
CITYInill
VtAs� ZIP�FEL.�(j�4�j
OWNER -BUILDER DECLARATION
IH ERERYA TRAIM UNDER PENALTY OF PERJUTTY THAT 1 AM EXEMPT FROM THE CONTRACTORS U.
CENSE LAW FON THE FOLLOWING REASCN (SEC. 7031.5 BUSNESSAND PROFESSIONS CODE: ANCTORS
PJAE WHICH REQUIRES A PERMIT TOCON'STR'JCT, ALTER WPROVE. DEMOLISH, OR REPAIR ANY STRUT
TORE. 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 LL
CENSE LAW (CHAPTER i (COMMENCING WITH SEC(tON TORO) OF D'. VISION J OF THE BUSINESS A'40 PRD.
ress*NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE eA515 FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION T031 BY ANYAPPLICAWT FOR A PERMIT SUBJECTS THE APPLICANT TO
A Ca AL PENALTY OF NOT MORE THAM FIVENUI ED DOLLARS (5500).):
0 L AS OWNER OFTHE PROPERTY. OR MV EMPLOYEES WITH WAGE 5 AS THEIR SOLE COMPENSATION.
WALL DO THE WORK AND THE STRUCTURE 15 NOT INTENDED OR OFFERED FOR SALE (SEC. 7011 BUSK
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF
PROPERTY WHO BUILDS OR IM
PROPERTY AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS
on HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED On
OFFEREOFORSI IFHOWEVER THE BUI DNGORMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
T)ON. THE OWNERBUILDER WILL LAI THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF 3ALE1
E1 L AS OVINEROFTHE PROPERTY. AL1 EXCLUSIVELY CONTRACTING PATH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. IoM. BUSINESS AND PROFESSIONS COLE,. THE CONTRACTORS LJ -
CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUJLDa OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS MTN A OONTRACTOR(S) LICENSED PURSUANT TO THE CONTRA C_
TORS LICENSE LAW),
OI AM EXEMPT UNDER SEC. B SP.C.FORTH:SFEASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM SIO
LICENSED UNDER PROVISIONS OF CHAPTER
.(COMMENCING WITH SECTION 7000( OF DIVAS K)N ] CF THC BUSINESS AVD PROFESs,o"s COCC. AND
LEY LICENSE 6 IN FULL FORCEANO EFFECT. /' G
LICENSE CLASS LIC. NO.
DATE L CCNTRAL'TOP IBQ,17Tt�+Li-i rL,��
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFlrw 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 SYSECTION 3700OF THE LABOR CODE. FCR THE PERFORMANCE
OF THE WORK FOR WI ITCH THIS PERMIT M ISSUED.
HAVE AND WILL MANTkN WORKERS' COMPENSATION INSURANCE. AS RFOJIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKE//p�$^' COMPENSATION INSURANCE CARNER AND POLICY NUMLIEn ARC:
CAMDEN! - wL,,,
POPOLICYNW BER �17jl, C7t_=
(THS SECT"q NEED NOT BL aa.n.ETED OF THE PERMIT 6 Fan a.E MU DEED DOLLAJLS (SI W ) OR LE'%
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHA NOT EMPLOY ANY PERSON H ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUB..';CT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 370O OF THE LABOR
CCIOE. I SHALL FAOIRTEWTH COMPLY WTII P 'VISIONS.
DATE: Cfy APPLICANT. _
WAANIN�L� TO SECURE WORKERS' NSAi�VERAGE IS UNLAWFUL, AND SHALL BE
SUB-'ECTAN EMPLOYER TO CRIMINAL PENALTIESM0 CML FWES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 770E OF THE LABOR CODE, INTER ESS AND ATTCRI FEES.
CONSTRUCTION LENDING AGENCY
I MERCBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOn W 41CH THIS PERMIT IS ISSUED (SEG a0P7, CIV C.),
LENDERS NAME
LENDERSADDRESS
1
CENT FY THAT I HAlE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION AS CORRECT.
t AGREE TO COMPLY WTH ALL CITY AND COUNITY ORDINANCES AND STATE LA'NS RELATING TO BUILDING
CCNSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVC-MENTIONED, PROPERTY FOR INSPECTION PURPOSES.
PE ENAME (PFUNT) 44J
SIGNAT EOH PER,IITTCE
11
PRESS
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APPLICATION '
DATE
PERMIT l]2
P/C
NUMBER `✓'�✓
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ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
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REAR
Ll
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SIDEISIDE
STREET RW
O
SIDE
PROPOSED USE
NO. DWEL.
NO.
NO.
UNITS
STORIES
BEDROOMS
IDESCRIPTION
SO. FT. FACTOR PSF
ADJ. AREANALUATION
lADDIRIEM
Garage/Carport
LUPalio/Deck
U-
0
PDD'JSpa
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Commercial
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Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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7
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
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PLUMBING
MECHANICAL
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INSPECTION FEE
ISSUANCE_-rI
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SHIP
ENERGYP/C?
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ENERGYPERMIT
RETENTION FEE:
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PRC -ALT FEE:
TOTAL FEES
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COMMENTS
/17
III NO.
PAID BY VALIDATION
WHITE—Deper hent Copy, YELLOW—Finance Copy. PINK—Assessor Copy.
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