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Home My WebLink About14904 (32)J� 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 JOBSITE ADDRESS "1T� G' lC ( t�vV o0� APN LOT TRACT OWNER 6 f:CL n � M `c L & It L_ e-u-rn � M�c L-+ lie- L_ C.u-f ADDRESS 7c tf 2,Y L % • C .I III% rLA� cc, d CITY DiDL-Y..zK`.1►'�a.r ZIP 9 1 LS TEL.`%D i 8Mb0 tIL,w APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PEIUURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- CENSE UW FOR THE FOLLOWNO REASON!SEC. 70.71.5 BJSINESS AND PROFESSIONS CODE: ANY CITYCR COUNTY WHKH REOUNEBA PEFO.RrTO CONSTRUCT, ALTER. BAPROW. DEMOUSH, OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE. ALSO RECUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED -STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. RINSE UW (CHAPTER P (CCIAMENCING WITH SECTION TOW) OF DIVISION D OF THE BUSINESS AND PRO- FESSIONSCODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP. TION. ANY VIOLATION OF SECTION 7031.6 BY ANYAPPLILANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACRAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SM)'❑LAS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. 7044. BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO,BUI DS OR IMPROVES THEREON. MID WHO DOES SUCH WORK HIMSELF OR HERSELF CR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF 000PLE- • TION, THE CiR-BUI DER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR IMPROVE FOR THE PURPOSE OF ME). O L AS O"WEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC TCFSI LICENSE LAW.). D I AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE ✓! ' O LT OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE is N FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE CONTRACTOR WORKERS'COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS. I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' —COMPENSATION. AS PROVIDED BY SECTION 37DO OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERT COMPENSATION INSURANCE. AS REOURED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERT COMPENSATION INSURANCE CARRIER AND POLICY NULIDER ARE: CARRIER POLICY NUMBER LOIS SECTICNNEPD NOT BE COMPLETED OF THE mw is FOnONE HLFTXIEDDDLIAnS (SIOMOiLES-1 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON N 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 COOS I SHALL FORTMMTH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT: I WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND .DOLLARS 15100.000). N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN I SECTION 3706 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY i 1HEREBY AFFIRMERFOF LNDEA PENALTY OFPERJURY THAT THERE MACONSTRUCTION UED(SEC. LLNDNG AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. CJ. I LENDERS NAME LENDERSADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CRUN Y AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. j � Leaf SIGNATURE , OF PERMITTEE GATE PRESS FIRMLY APPLICATION PERMIT O 3�/zo/ DATE ✓ NUMBER ISSUE 'TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE Ll STREET RW ❑ SIDE ❑ PROPOSED USE -_ ND S ti NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAJVALUATION SFRIADDIREM Cl) GaragarCarport WPa!iOJDeck LL PoOVSpa ZRG -Roof Commercial - m Valuation ADJ.AREA QUANTITY/DESCRIPTION FEE a c P C+ 1511411 Till U LL U W J W Tr 10 -9e) 2 1 1 e- o• v CL a I I P_:toml e 0C, o00 3 Y •[' D U Z U W CONSTRUCTION PLAN REVIEW a3� • ELECTRIC K PLUMBING I ,I„ -r7 MECHANICAL INSPECTION FEE ISSUANCE UU I� SMIP nND B AR o - ENERGY PIC `� S AFETY ENERGY PERMIT RETENTION FEE: PRE -AL 7 TOTAL FEES j�j�i COMMENTS z2 rl RECPT NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—F!nanca Copy, PINK—Assessor copy. GUUJtNHUU–tn01,0py, umttN—Appganrs wpy