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Home My WebLink About15051 (19)J� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley chive Suite 190 (909)860.3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION. JOBSITE ADDRESS X688 6A&LW__A1ACE APN LOT TRACT OWNER ell ADDRESS CITY ZIP TEL APPLICANT TEL. CONTRACTOR ADDRESS - CIL -CA;'D 1TAMC , CRY ' ZIP `117/( TEL4264/y'�� ARCFUENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM CINDER PENALTY OF PEFUJRY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESAPERMn' TO CDNSTRUCT,ALTEK IMPROVE. DEMOLISH, OR REPAIRANY 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 U CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 70DO) OF DIVISION ] OF THE BUSINESS AND PRO FESSIONS CODE) OR TRATHE OR SHE IS EXEMPT THEREFROM ANOTHE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 155001.} O L AS OWNER OF THE PROPERTY, OR MY EMPLOYE ES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044, BUSI- NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOTAPPLY 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 THATSUCH IMPROVEMENTS ARE NOT MENDED OR OFFERED FOR SKE IF, HOWEVER. THE BULDINGOR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPLE- TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD ORE). IMPROVE FOR THE PURPOSE OF SAL O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC 7944, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U• CENSE LAW DOES NOTAPPLYTOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IMM LICENSED UNDER PROVISIONS OF CHAPTER 0 (UYOMMENCNO WITH SECTION YOM) OF DIVISION ] OF THE EUS:NESS AND PROFESSIONS CCOE.AND MY LICENSE IS N FULL FORCE AND EFFECT. t , LICENSE CLASS 3 G LIC. NO. DATE �LO! &10 CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLIOWNG DECLARATIONS: I HAVE AND WALLMAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS COMPENSATION,ASPROVOEDBYSECTON]7o00F THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _11 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION 37DO OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MYRS' CONDENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER / N+��rs I, �V�p POLICY NUMBER ,QCi9//DlX1�_ A C05 %�/O �L i (THIS SECTION NEIDNOT BE C OMF ETECOFTIE POW IS FOR ONE HIO MMUAM(SIW)ORUES% I CERTIFY THAT IN THE PERFORMANCE OF THE WOnK FOR WHICH THIS PERMIT IS ISSUED. I J SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF MPTHAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENECTION 3700 OF THE LABOR COOE.IS ALL ORT}TMTH COMPLY W� 1 DATE: O� APPLICANT: j WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRM'NAL PENALTIES AND CML FINES UP 70 ONE HUNDRED THOUSAND DOLLARS (5100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN 1 SECTION 3708 OF THE LABOR CODE. INTEREST, ANDATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY )_ 1HEREBY AFFIRMUNDERMANCE orPENALTY OFPERJURY ICHTHAT IS PE MACONSTRUCTUED(S C, LENDING AGENCY FOR 744E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097.0V C.). - LENDER'S HALE 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 yCONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMRTEE NAME (PRINT) r](GNAT EOF PERMITTEE PRESS FIRMLY. APPLICATION/___V PERM"�I PIC DATE NUMBER Sa # ISSUE// -•� b TYPE OCC DATE__ (I�--d-" CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE -r t4, NO. DWEL. N UNITS ST S ROOMS DESCRIPTION SO, FT. FAT SF ADJ.AREA/VALUATION SFR/ADD,'REM Garage/Carport WPatio/Dack L- POOvSpa Q Z Re -Roof 0 Commercial co Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U 0 U W J W U 2 CO 1 J a a U_ Z Q S U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBINGLL— MECHANICAL INSPECTION FEE . A �/��,� ISSUANCE�A SMTP ENERGY P/C ENERGY PERMIT L RETENTION FEE: L PRE -ALT FEE: S TOTAL FEES COMMENTS RECPT. NO. PAID By -2 VALIDATION27— WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy. 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