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Home My WebLink About15042 (19)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES c 21660 E. Copley Drive Suite 190 PRESS (909) 860.3195 Fax (909) 861-3117 . pA. BUILDING PERMIT APPLICATION FIRMLY JOBSITE ADDRESS150 APN LOT TRAC OWNER1I LLL ADDRESS .3 r liQ.1C� 4AtA SSE hom CITY �a-33G ZIP Zi01 TEL. APPLICANT TEL. CONTRACTOR -4 �'x• ADDRESS ��''+L� CITY PkA4'.?r+PL ZIP :146 TEL.71�! SrL B9/SI ARCKENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4 CENSE LAW FOR THE FOUDWNG REASON (SEC. 7031.SBUSINESSAND PROFESSIONS COCE:ANYCITYOR COUNTY WHICH REDUIRESAPERMrTTO CONSTRUCT,ALTER IMPROVE. DEMOUSH.OR REPAIR ANY STRUC. TORE. PRIOR TO RS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PACIVISKNS OF THE CONTRACTORS U - CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION. ANY VIOLATIDN OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE ANY DOLLARS ($500)1: O t AS OWNER OF THE PERTY, PROOR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK AND THE STRUCTUAC IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7041 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 FIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF. HCWEVERTHE SUaDNG OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPILE - TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR IMPROVE FORTHE PURPOSE OF HAVE O LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS 1'O CONSTRIA:T TETE PROJECT (SEC. 70". BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U. CENSE LAW DOES NOTAPPLY70AN OWNER OFA PROPERTY WHO SUFDSORIMPROVES THEREON. AND W1O CONTRACTS FOR SLICK PROJECTS WITHA ODNTRACTOR(S) LICENSED PURSUANT TOTHE CONIRAC- TORS LICENSE LAI). O I AM EXEMPT UNDER SEC. B. L PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 0 (CCMMENCNO WITH SECTION 7000) OF DIVISION ] OF THE BUSINESS AND PROFESSIONS CODE. AND W LICENSE IS N FULL FORCE AND EFFECT. LICENSE C S `-� DATE)ycoNrRACTnRCYM�aa/�/ Nr 6 6KML WORKERS• COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATION& I HAVE AND WILL MANTAN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATI N. AS PROVIDED BY 5ECTION 77M OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. I IHAVE AND WILL MAINTAIN Y/OMERS'COMPENSATK)N INSURANCE,AS REWIRED BY BECTON 37M OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS COUPENSVON IN`U ECARR:Eq ANO POLICY NUMBER ARE: CARRIER I POLICY NUMBER (nas wcn NWED NOT BECO PLFTEDOF THE PERMIT MFOACNE HUNDRED DCLUAS(31001 ORLES51 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I 1 SHALL NOT EMPLOY ANY PER SON W MANNER SO AS TO BE .F SUB.ECTTO7HE j WORKERS'COMPENSATKN LAWS a IFORNIAAND AGRCE7 4 FISNOULD BECOME SUBJECT TO THE WORMERS' ENS PRONSKNS OF SE T J ]704 OF THE LABOR LODE. S FORTIMITHCOM PL WITH SEPROVISONS- r DATE: APP$ .— i WARNING: N EMPLOYE SECURE CRIMINAL PENALTIES AND CIVIL COVERAGE IS ONE HUNDRED L. AND SHALL BE SUBJECT AN EMPLOYER TO CW4:NAL PENALTIES AND CML FIVES UP 70 ONE HUNDRED THOUSAND COLLARS (SIM. 0007, IN ADDITI N TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN J SECTION 3700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. u CONSTRUCTION LENDING AGENCY )_ 111EREBY uImDER PENALTY OFPERJURY TMT IS PE ISACONSTRUCTION UED(SEC LEND NO AGENCY FOR THE PERFORMANCE OF THE WORK FOR YAiNi1 THIS PERMIT IS ISSUED (SGC ]007, CN. C). 1 - LENDEfYS NAME LENOEITSADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE TMT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, ANO HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FON INSPECTION PURPOSES, Il�iilp►TNL. 1,.�i77� O E EE NAME (PRINT) SKINAIUREOFFILAMITTEE DATE C APPLICATION � PERMIT / 1(,� 1 PIC DATE NUMBER V 'tel X ISSUETYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE Al NO. DWEL O. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFRIADDIREM U) Garage/Carport W Patio/Deck LL PooVSpa Z Re•Roof Commercial - M Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U cc 0- U W J w 0 Z_ m Z 4 x U W 2 CONSTRUCTION PLAN REVIEW ELECTRIC L C^'^�•-j` PLUMBING /nI MECHANICAL n(� INSPECTION FEE ISSUANCE AA ti CITY tt CITY UL' LII'..."::J-\:J '✓:' f\ c SMTP F3LIIJ I v':_T %� 1) ✓J,�1'..._ i Y ENERGY P/C •�I ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES / COMMENTS T RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy. PINK—ASSOSSof COPY, GOLDENROD—FLNI L:Opy, GHttN—APpucant-S VOPY