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Home My WebLink About18437 � CITY OF DIAMOND BAR L � r t.f�', � � DEPARTME�.'T OF COMMCJNrt'Y&DEVELOPIv�NT SERVICES � I � �T,� 21825 E.Copley Drive I �� (909)860-3195 Fax(909)861-31 l7 PRESS -��^ BUILDING PERMIT APPLICATION FIRMLY } JOBSITE / n � p n APPLICATION � I `�PERMIT P/C o ADDRESS_�� n��/lW r �i • DATE �•�OtiNUMBER # � ISSUE TYPE OCC APN LOl" TRACT _ _ DATE CONST. GROUP � OWNER �t O o ADDRESS e G �r � ZONING SETBACKS z CITY ZIP�� 7E O ^� FRONT RW ❑ I � APPLICANT e- �s f u� TEL, � REAR � z SIDE/SIDE STREET RW ❑ � a CONTRACTOR � SIDE ❑ o ADDRESS ~ PROPOSED USE � (STI h �Q, �'�"� o CITY�Q�O�9 C� ZIP TEL. �7 w ARCH/ENG/ z DESIGNER� w — NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS cn - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlREM O Q I MEREBY AFFlRM UNDER PENALTV OF PER1UflV THAT I AM E%EMPT FROM THE GONTR4GTOR5 LI- Gdf8CJ0/CBfpOf1 W CENSELAWFORTHEFOLLOWINGPEASONj5EC.1031.5BU5ME55ANDFROfES510N5CODE:ANVCITYOR (/� CJ COUNTVWHICHREOUIflESAPERMITTOCONSTRUCT,ALTER,IM�ROVE.DEMOLISH,OFREPAIRANViTRUC- w TURE,PRIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT rOR SUCH PERMIT TO FILE A SIGNED W PdtiO/DBCk STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF TNE CONTRACTOf1S LI� � CENSE LAW(CHAPTER 9(COMIAENCING WITH SECTION]000)OF DIVISION 3(1F 7HE BUSINESS AND Pao- � POOUSpB O FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHcqEFROMANDTMEBA515FORTHEALLEGEDEXEMF- Z �� V TION.ANV VIOIATIONOF SECTION)0�1.5 Bv qNYAPPLICAN'GOR A PERMIT iU9JEG�S"lHE APPLICANTTO Re-Root � � ACIVILPENALTVOFNOiMORETHANFlVENUNDREDDOLlARS(f5o0).)� - � ❑I.ASOWNEROFTHEPRbPERTY,ORMYEMPLOYEESWiTHWAGE5ASIHEIRSOLECOMVENSATiON, � CORIIf1EfCIdI Z WILL DO TME WORK,AND THE>TFUGTURE IS NOT INTcND[D ON OFFERED FOH SALE;SEG.]044,BUEI� J � NE55 AND PROFESSIONS GODE::THE GONTRAGTORS LICENSE LAW GOcS NO�APPLV TO AN OWNER OF = PROPERTV NT10 BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WOPN HIMSELF OR HERSELF OF � THROUGH HIS OR HER OWN EMPLOVEES,PROVIOED THAT�UCH IMPROVEMENTSARE NOT INTENOE�OR m w OFFEREOFORSALE.IF,HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDWIiHINONEYEAROFCDMPLE- 0 TION,THE OWNER-Bl11LDER WI-_L HAVE THE BURDFN OF PPOVING�HAT HE OR SHE 01�NOT BUILD OH Z IMPqOVEFORTHEPURPo5EOF5ALE). _ ❑I,ASONTJEROFTHEPROPERTV,AME%CLUSIV[LYCONTRACTINGWITHLICENSE�CONTRACTORS W � TO CONSTRUCT THE PROJECT(SEC.]osa,BUSINESS M!D PROFESSIONS CODE:THE CONTRACTORS LI� VaW2�lOfl A�J.AREA W CENSEUW�OESNOTAPPLYTOANOWNEROFAPROPER'VWNOdU1IDSORIMPROVESTHEREON,AND — - � WFIOCONTRAGTSf095UGHPROJECTSWITMAGONTflAGTOq�S)I.IGEM1SEDPURSUANTTOTHEGONTRRC- QUANTITY DESCRIPTION �E Y TORS LICENSE LAW). � Cl I AM EXEMPT UNDER SFC. 8.8 P.C.FOR THIS PEASON J � a � U � -- OC DATE OWNER U Z w � LICENSED CONTRACTOFS DECLARATION w ¢ 2 I HEREBVAFFIFM UNDER PENAI_TV Of PEftJURY THAT I AM LICENSED UNDER PROVISIONS OF GHAPTEH � d 9(COMMENCING WITM SEC�IO�]000)OF D'iVISqN 30F TNE BUSINE55 FND PPO�ESSiONS CODE,AND Z X MY LICENSE IS M FU FO CE AND EFFECT. ry; A � W �/ [I] � IICENSECL4SS -' S "1�_ LIC.NO. � F, G -,� ��p J U �ATE If"�/1/0� CONTRACTOfi ys„__. d w �T� � WORKERS'COMPENSATION DECLARATION Q � I HEREBVAFFIRM UNOEF PENN_TV OF PERJUflY ONE OF THE FOLLOWING OECIARATIONS: Z Q � I MAVE AND WILL 1.1AINT4IN A CERTIFICATE OF CONSENT iOSELF-INSURE FOR WORKERS' _ Z COMPENSATION.AS PROVIDED BY SECTION 3]00 nF TNE LABOR CODE,FOR THE PERfORMANCE U QOFTHE WORK FOR WHIGM THIS PEriMiT IS ISSt;EO. � W I HAVE AND WILL MAINTAIN WORKERS'COMPFNSATI(]N INSl1PANCf.AS RFpUIRE�BV SECTION Q ]OOOF THE�ABOR CO�E,fOR THE PEFFOPMANCE OF THE WORK FOR WHICHTHIS PERMIT IS ' ISSUE�.MV WORKERS'CDMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION � GARRIER_��C.� PLANREVIEW __. _ �� • ZaoucvNUMeea ��s'� d ELECTRIC ___ ¢ o �rriissEcraNNEmr�oreEcorna�ErEooFn�EaEw.ur�src,kowEHuroaEomiaas�sim�oa�Ess� PLUMBING Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I5155'JED.I MECHANICAL C'� SHALL NOT EMPLOY ANY PEFSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO TME (/� WORKERS'GOMPENSA'"ION LAWS OF CALIFORNIA,ANDAGREE TMAT IF I SH�ULD BECOME INS"ECTION FEE � SU9JtCi 10 TME WORF;EFS'GOMPENSATION PROVISIONS Of SECTION 370�OF THE LABOR - CODE,IS� �^HALLFOR�ITHCOMPLVWITHj1�p PROVI51 5. ISSUANCE � )a� r SMIP p DATE'. � ^�/ �APPLICANT: 1 7 0 J WARNING:FAILJRETO SECUflE WORKERS'GOMPENSRTION COVERAGE IS UNLAWFJL,AND SHALL BE ENERGY P/C _ LL SUBJEGTAN EMVIOYEH i0 GHIMINAL VENALIIES AND CIVIL FINES UP lD ONE HUNDRE�TMOUSANp ENERGY PERMIT OOlLARS(51 oa,Doo�.IN ADDItION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN � SECTION31080FTHELABORCODE.INTEREST,ANDATTORNE�'SfEES. RETENTIONFEE: ' I a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � � I O __ __.. ____-___-___ � IHEREBVAFFIRMUNDERPENALTYOFPEFJIiRYTHATTHEREISACONSTFUC?IONLENOINGAGENCY FOR THE PERFORMANCE OF iHE WOFK FOR WHICH iHIS PEFMI7 IS ISSUEU(SEC.309],CIV C.). W = LEN�ER'SNAME � - H LEN�ER'SADDRESS � TOTALFEES � I GERTIFV iHAT 1 NAVE READ Th115 APPLIGATION AN�STATETHFT THEABOVE INFORMATION IS CORRECT I ��'� w I AfiREE TO COMPLY WITH ALL I;ITY ANO COUN'YORDINANCESAN�STATE JIWS HELATING TO BUIL�ING � CONSTRUCTION,ANDHEREBV�4UTHORIZEREPRcSENTATWESOFTHISCOUNTYTOENTERUPiINTHE � ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. Z � GOMMENTS o _ ,.� J� �S � - __ _- - _ - m P iil EE NAME i RINT� �) �� /� Q �/�� "�I UJ ! /� -\��7 V � SIGM1ATIiqE OF PERMITT ' �MiG.... = RECPT NO. PAID BY VALIDATION ~ WHITE-De artmert Co YELI.OW-Finance Co PINK-Assessor Co GOLDENR File Co GFEEN-A IicanPs Co P PY� PY. PY. PY. 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CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION L YQ.C1," PRESS FIRMLY JOBSITE ADDRESS I,;/ APN LOT TRACT OWNER AN-PiaA ADDRESS e G' CITY ZIP C TE t'1 ^.1 APPLICANT e.TEL. CONTRACTOR ADDRESS 420A,014149 oAZP-42"'- CITYOa00r1 CL-JZIPYjUff TEL. -7 ARCH/ENG/ 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. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,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 IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI' CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THE--RE FROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICAN T FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(1500)): - ^ 1,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS T HEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW GOES 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 INTENDED OR OFFERED FOR SALE. IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WI-_L HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI. CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.) . CI I AM EXEMPT UNDER SFC. B&P.0 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 30F THE BUSINESS AND PROFESSIONS CODE,AND FECT MY LICENSE IS IN FU FO CEEAND EF FF C LICENSE CLASS 1 "1 LIC. N0. DATE CONTRACTOR" WORKERS'COMPENSATION DECLARATION I 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 3700 OF THE LABOR CODE, FOR THE PERFORMANCE JJ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED yy��[[ \L HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE C RRIER AND POLICY NUMBER ARE A CARRIER IN-e- �y' � w d POLICY NUMBER)R--57-/J I7 Y' (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR 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'COMPENSA"'ION 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 PROVISI S. DAT APP ICANT � /? E. T( L 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 IS150.550),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.) LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 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 PROPERTY FOR INSPECTION PURPOSES. 0-I'LI CA.e mot-S P AI EE NAME RINT) 1 �rVl G /^' / T � n SIGN ATL;RE OF PERMITT APPLICATION PERMIT P/C DATE'./ CUMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ PROPOSED USE 0 Z�X I S T i A A A j r0 7VII1-7JA0 L 9-1111AA N0. N0. DWEL. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM Garage/Carport W Patio/Deck LL PooL/Spa Z Re-Root Commercial Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U I- U W UJ Z m a Q U Z 2 U W CONSTRUCTION 'CA PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INS?ECTlON FEE ISSUANCE SMIP 0 ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES JI COMMENTS COMMENTS _ RECPT N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy