HomeMy WebLinkAbout15013CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
�w 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-31.17
BUILDING PERMIT APPLICATION
JOBSITE
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APN LOT TRACT
OWNERCGk�1D Ki►►n
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CITY ZIP TEL., t'- 6j� ] v
APPLICANT TEL.
CONTRACTOR L
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DESIGNER
ADDRESS _—-- --- — ---- -
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 70.91 6 BUSINESSAND PROFESSIONS CODE ANYCITY OR
COUNTY WHICH REQUIRESAPERMn TO CONSTRUCT. ALTER, IMPROVE. DEMOLI5H, OR REPAIR ANY STRUC-
TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT 10 THE PROVISIONS OF THE CONTRACTORS LI.
CENSE LAW (CHAPTER 9 SHE
WITH SECTION 7000) OF DIVISIONS OF THE BUSINESS AND PRO-
FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).)
❑ I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COM-ENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7064, 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 HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INR ENDED OR
OFFERED FOR SN.E IF,HUWEVER THE BUILDING ORIMPROVEMENTIS SOLD WITHIN ONE YEAR OF COUPLE
TION, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING fHAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
❑ 1, AS OWNER OFTHE PROPERTY, AM EXCI USIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70U. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI.
CENSE UW DOES NOT APPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHOCONTRACTS FOR SUCH PROJECTS WRHACONTRACTOR(S) I ICENSEO PURSUANT TO THE CONTRAC-
TORS LICENSE LAW)
❑ IAM EXEMPT UNDER SEC B S P C FOR THIS REASON
DATE OWNER,
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF 1 HE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS. IN FULL FORCE AND EFFECT
LICENSE CLASS} 6,31 LIC NO�Ii,,
DATE :i.-wc4a '101,1 -_ CCNTRACTOR ma?
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALI Y OF PERJURY ONE OF THE FOLLOWING DECLARA110N,S
—I HAVE AND W IL L MAINTAIN A CEF PFICATE OF CONSENT TO SELF -INSURE FCR WCRKLRS
COMPENSATION, AS PROVDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IB 155UED
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS HEOUIRED BY SECTION
370D OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH TI IIS PERMIT 15
ISSUED MY WORKERS' OCMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER _wo
POLICYNUMBER Zf&54-'& -VAJ1 T_0 ,,o / 7"3 r]
(rHS SECTION NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE 14*10IED DOE LARS (5:00) Oil LESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOUT D BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECT ION 3700 THE LABOR
CODE, I�S[H�ALL%FORTHWITH COMPLY WI OSE PROMS
DATE +e'•'"" APPLICANT
WARNING- FAILURE TO SECURE WORKERS'C MPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097. CIV C)
LENDER'S NAME
LENDER'S ADDRESS
ABOVE -MENTION ED PROPERTY FOR INSPECTION PURPOSES
ERMI NAME(PRINT) _ ,�j �•� ww'�
E OF PER 11 E DATE
PRESS
FIRMLY
APPLICATION PERMITC
DATE `v�'�� `� NUMBE
ISSUE TYPE OCC
DATE_ CONST. GROUP
ZONING SETBACKS
FRONT RW Ll
REAR Ll
SIDE/SIDE STREET RW CI
SIDE Ll
PROPOSED USE ?_9FkV>+' ` i�9XQ4'rr�i:&Kj0 , IAI1 7�11u_ t)L-4�te?ki
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NO. DWEL. NO. NO.
UNITS STORIES _ BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA(VALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck
LL11
L-
PooVSpa
ZRe
-Roof
Commercial
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Valuation _ _,�-_� _ ADJ.AREA _______
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE -•) '
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ISSUANCE _--_—_-- _ . -----__-- -- -- t
SMTP
ENERGY P!C
ENERGY PERMIT - •- -•. -,- a� -
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RETENTION FEE:_ :,-TTT — -- - — -
PRE -ALT FEE
TOTAL FEES
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COMMENTS
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RECPT NO. _ PAID BY,1 VALIDATION
WHITE—Department Copy, YELLOW --Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
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