HomeMy WebLinkAbout15035 (17)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
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL
CONTRACTORC o P EC C A
ADDRESS
CITY C%OROlu1 ZIP 171 TELC]Jef 7, ?Z Kiy
ARCH/ENG/
DESIGNER J,u&JjJa1VA/L,- R; So V n&6_S _
ADDRESS 7 /'hsLaC"" V
CITY SS!JIAjit ZIP9I� ISS TEL -0
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT TAM EXEMPT FROM THE CONTRACTORS LI*
CENSE UW FOR THE FOLLOWING REASON (SEC. 7071.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUMIES A PERMIT TO CONSTRUCT, ALTER IMPROVE• DEMOLISKCR REPAIR ANY STRUD
TUBE. PRIOR TO ITS SSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW (CHAPTER 2 (COMMENCING WITH SECTION 7000) OF DIVISION ] OF THE BUSINESS AND PRO-
FESSIONS OR THAT HE OR SHE IS EXEMPT THE REF ROM AND THE BASIS FOR THE ALLEGED EXEMP.
TPN. ANY VIOLATION OF SECTION 7071.6 BYANYAPPLOANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACRAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSWl):
CI L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES PATH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70u. BUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW 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 IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT 1S SOLD WITHIN ONE YEAR OF COMPLE-
IRON, THE OWNERBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FORTHE PURPOSE OF SALE}
0 L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70U, BUSINESS AND PROFESSIONS COI: CONTRACTORS THE CORACTORS LI
CENSE LAW DOES
NOT APPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO
CONTRACTS FOR SUCH PROJECTS WITH CONTRACTOR(S) LICENSED PURSUANT TO THE COWRAC
TORS LICENSE LAW.).
O IAM EXEMPT TIMER SEG B. L P.C. FOR THIS Rc-A SON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
L HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COAIMENCWG NTH SECTION 70001 OF DIVISION ] OF THE BUSINESS AND PROFESSIONS COLE, AND
MY LICENSE IS N FULL FORCE AVD EFFECT,
LICENSE CLASS C--4 O LIC. NO.
DATE CONTRACTOPI
�7 WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFNNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 CF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
NAVE AND WILL .1. WORKERS' COMPENSATKIN INSURANCE. AS HEOUIRED BY SECTION
7700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICIN THIS PERMIT IS
ISSUED. MY WOR RS'CO•MP1ENS ONINSURANCECARRIERANO POLICY NUMBER AAE:
CARRIER
POLICYNUAWER d
(MS SECTION NEMNOT BE COWLETEDOF DE PERMIT IS FOR ONE HUIND >CDMUARS (1100)0R LESS}
1 CERTIFY THAT INTME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT tS ISSUE0,1
SMALLNOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECTTOTHE
WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
CODE.
I SHALL FORTHWITH COMPLY W7A.0
P /yVISIONS.
DATE: W -DLO- APPLICANT:
WARNING- F IAIWRETO SECURE WtlRKERTOOION COVERAGE IS UNUWrUL. AND SHALL BE
SUBJECTANEMPLOVERTOCR:MINALPENALTIMLFWES UP TOONE HUNDRED THOUSAND
DOLLARS (11100,000), IN ADDITCUTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 7706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'6 FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PEPUUFTY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 7027, CIV C.).
LENDERS NAME
LENDEPrSADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE A50VE INFORMATION IS CORRECT,
AGREE TO COMPLY NTH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AVTHIORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE.MENTIONED PROPERTY FOR INSPECTION PURPOSES
Y-1 IAL /'1AI�/F11 J?E21Y
PE 'TEE NAME (PAINT)
SIG U O PE MITT E OA!
PRESS
FIRMLY
APPLICATION j
/n\ PERMIT
DATE `
-4561�P/C
V v NUMBER I �J(J
i1
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDMDE STREET RW
❑
SIDE
PROPOSED USE
i
NO. DWEL.
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
\
Cl)
Garage/Carport
WPatiomeck
L=-
Pocl/Spa
Z
Re -Roof
Commercial
-
5
Ell
Valuatlon
ADJ.AREA
QUANTITY DESCRIPTION
FEE
Q
L
H
� V
W
J
w
-
0
Z
Fn
J
CL
U
Z
Q
U
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
�•
MECHANICAL
INSPECTION FEE
ISSUANCE
IhLl
SMIP
ENERGY P/C
C11y 017DIAMOND
ENERGY PERMIT
l ) NN
'r.l l
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
! 7
COMMENTS
RECPT. NO.
PAID BY _
VALIDATION
WHITE --Department Copy. YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy