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HomeMy WebLinkAbout15109 (17)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Shite 190 (909) 860-3195 Fax (909) 861-3117 PRESS FIRMLY BUILDING PERMIT APPLICATION JOBSITE ADDRESS .Zj�' �r� G r.T��i?�•J �n; r:7�*, J� /rCC APN LOT TRACT OWNER '71:LokzJ7 .Cf -r' ADDRESS 74e!�!�f-� !rz.l.-ji! Ll %fit r -l�rJ CITY 7 ' t' ' ZIP TEL APPLICANT TEL."'F CONTRACTOR ADDR C[TISS ARCH/ENG/ / DESIGNER ADDRESS C - CITY%tL-tj(t%ice ZIPr _ TEI.�r�"-jr OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PCRIURY THAT I AM EXEMPT FROM THE CONTRACTORS L4 CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031 .5 BUSNESSAND PROFESSIONS CODE:ANYCM OR COUNTY WHICN REGUUIES A PEWITTO CONSTRUC T - ALTER SAPROVE. DEMOUSH,OR REPAIR ANY STRUO TURF, PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION IWO) OF DIVISION 5 OF THE BUSINESS AND PRO. FESSONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION.ANY VOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).)! C L AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WOW, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDSOR 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 FORSALE F,HOWEVER. THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE- TICK THE OWNER'BUILDER WILL HAVE THE BURDEN OF PROVING THAI HE OR SHE DID NOT BUILD OR I APNOVE FOR THE PURPOSE OF SALE). E3t AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT ISEC. 7044, BUBINESS AND PROFESSIONS COOS THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR W PROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). O IAM EXEMPT UNDER SEC. T B. i P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION IHEREBYAFFAM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OFCHAPTER S (OOMMENCNG WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS OCOE,AND MY LICENSE IS IN FULLLL FORCE AND EFFECT. LK:ENSU CLASS ` �T LIC. NO. DATE .7 �Z-`���f✓C/' CONTRACTOR1iLIF(:. 57.y '-Nr•��rf. WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECIARATIoNS: , U _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 7700 OF THE LABOR CODE, FOR THE PERFORMANCE `' OF THE WORK FOR WHICH THIS PERMIT O ISSUED. w I HAVE AND WALL MAINTAIN YORKERS'COMPENSATION INSURANCE. AS REQUIRED BY SECTION 7700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARR'ER AND POLICY NUMBER ARE: CARRIER-1-I�}-f1-�:.�%aI Nr1 �-, ' .•� +`. POLICY NUMBER ( 1 (DIS SECTION NEEDNOTBEDDLFI-ETEDOFTIC PERMTIS WRONE H1JN0nED DDIAFS RfOgon LESS] 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THS PERMIT tS ISSUED, I SHALL NOT EMPLOY ANY PERSON INANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 77000E THE LABOR CODE.1 SHALL FORTHWITH COMPLY WITHITHOSE PROVISIONS. DATE: APPLICANT: WARNING,- FAILURE TO SECURE YORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL Be SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND COIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (6100.0001. IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 5705 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGCNCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 7097. CIV C.). LENDERS NAME LENDER'S ADDRESS I CERTIFY THAT 1 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 CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED P.7ERTY FO��CT PURIjS. L+r• �Ft� rpt l� crt PE EE NINA RI 13 1 IGNATURE-OF PLRMIrTeC DATE APPLICATION5' Le,7) PERMIT JP/C ©G J , DATE NUMBER ! III 1 ISSUE TYPE OCC DATE CONST, GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW . ❑ SIDE p PROPOSED USE NO. DWEL NO. UNITS STORIES BEDROOMS DESCRIPTION SO. Fr. FACTOR PSF ADJ. AREA/VALUATION SFFVADDIREM Cl) GaragafCarport W PatiofDeck O- Pool/Spa ZRe -Roof CI Commercial - m Valuaticn ADJ.AREA QUANTITY DESCRIPTION FEE Q U H U W w Z z m J a J Q - U Q U _ _ L `'�' CONSTRUCTION C, •!' PLAN REVIEW }— ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE UD SMTP JEL ENERGY P/C ENERGY PERMIT RETENTION FEE:: PR% F .. jCl TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE -Department COPY. YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy