HomeMy WebLinkAbout14904 (29)ri
DIAN01U' BIUI i
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
-
t)-b C a 1
ADDRIESS -�1a lJ? I C ( [
DATE 4e CONST. GROUP
APN - LOT', TRACT
OWNER b- CtQ--
ADDRESS ';j.�( 2ts' Ye Gni rt�f.P w �a J. r- i•
CITY �'`l law ,i�.�I� S0. rr ZIP k-7C:S TEL.^kRi S'100411164-
'10041164APPLICANT
APPLICANTI TEL.
CONTRACTOR
ADDRESS,,
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER I%ENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FORTHE FOLLOWNi REASON (SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH.REQUIRESAPERMITTO CON579UCT,ALTER, IMPROVE, DEMOLISH, OR REPAIR ANV STRUC-
TURE, PRIOR TO ITS ISSUANCE ;'ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENTTHAT HE CR SHE ii LICENSED PURSUANT TO'THE PROVISIONS OF THE CONTRACTORS U -
CENSE LAW (CHAPTER'S (COMM :NCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) ORTHAT HE OR SHE is EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATIONOFSECT' 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVILPENALTY OF NOT MORE 14AN FIVE HUNDRED DOLLARS ($500).):
(31. AS OWNER OF THE PR ERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO. THE WORK, AND THE S RUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFES310NS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO ButOR 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 IF HOWEVER, THESUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COM PLE.
'TION, THE OWNER-SUILDER WII.� HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FORTHE PURPOSED SALE).
❑ I, AS OWNER OFTHEPR PERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
:TO CONSTRUCT THE PROJECT ED. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- -
''CENSELAWDOESNOTAPPLYT
AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
- WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTOTHE
CONTRAC-TORS
LICENSE LAW.).
L7 I AM EXEMPT UNDER SEC. S. & P.C. FOR THIS REASON
DATE _0 Q
..r-^- -
OWNER
- LICESED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION X7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR -
WORKERS;' COMPENSATION DECLARATION.
I HERESYAFFIRM UNDER PENALTY OFPERJURY ONE OFTHE FOLLOWING DECLARATIONS:
_IHAVEANDWILLMAINT INACGRTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS P;VIDED BySECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE; AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(rHIS SEC ION NEED NOTBE COMPLETEDOFTHE PERMITL4 FORCNE HUNDREDDOLLARS ($1 W)OR LESS).
I CERTIFY THAT N 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 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
. DOLLARS i$1(0,D00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37080E THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER. PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THEABOVE INFORMATION IS CORRECT
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBYAUTHORQE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
BO
d < 1 \ C. Com- c- L— -0— -
l 4
,PERMffiggEF j1A\ME (PRINT)�'I
SIGNATURE OF PERMITTEE DATE
PRESS
'FIRMLY
APPLICATION PERMIT P/C cI
DATE l3' ;.NUMBER #
ISSUEar,, / ' TYPE ' OCC
DATE 4e CONST. GROUP
'ZONING SETBACKS
FRONT RW ❑
REAR
SIDE/SIDE STREET RW p.
SIDE ❑;
PROPOSED USE Do Selk
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION'
SFR/ADDIREM - -
(1)
Garage/Carport
W
Patio/Deck
V-
Pool/Spa 00
Z
Re -Roof
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE'
L)
W
W
Z�.
'1 Ad sg,
,[yy,,IIL
6
OL
Z
Q
W
CONSTRUCTION (.
_�
PIAN REVIEW?:, s'-_' a
ELECTRIC T
PAID 5,•�' �I � "3 p
MECHANICAL I^
INSPECTION FEE
ISSUANCE MAy 0 3 d000
r
SMIP .. , ,u-
ENERGY P/C a
A—ND- S.�4
..r
ENERGY PERMIT -
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES�i i ►
COMMENTS -
RECPT. NO.PAID BY VALIDATION
VVHII 1 t—LUepartment Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy