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Home My WebLink About14958 (17)r 0 J !� CITY OF DIAMOND BAR n DEPART14ENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 %A BUILDING PERMI APPLICATION JOBSITE J 6 500 �o1 /ay_� 6 j .� GaA , � ADDRESS I `-��/�+ V APN L T TRA T OWNER ADDRES CITY ' r ZIP I F TEL. APPLICANT TEL. CONTRACTOR 1 ADDRESS CITY 63 ZIP j TEL. 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 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIREB A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOUSH, OR REPAIR ANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (1500).): ❑ I, AS OWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR 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 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 INTENDED OR OFFERED FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT 15 SOLD WITHIN ONE YEAR OF COMPILE - TION, THE OWNER -BUILDER WILL 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 EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. CENSE LAW DOES NOTAPPLY TO AN OVMER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRAOTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). D 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION a OF THE BUSINESS AND PROFESSIONS COD�AND MY LICENSE 15 H FULL FORCE AND EFFECT. LICENSE C r, LIC. NO. 7 DATE d CONTRACTOR__ WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' CC�APENSATKON, AS PROVIDED BY SECTION 37000P THE LABOR CODE, FOR THE PERFORMANCE OR THE WORK FOR WHICH THIS PERMIT IS ISSUED. HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 9700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS CARRIER . MY WORK .® MP SATIDN IN URANCE CARRIER ANDPOLICY NU ER ARE: POLICY NUMBER VHSSECNON NEEDNDT BE 00MPLETEDOFTHE PERMIT IS FOR CNE HUNDRED DCUTAFLS ($100)OR LESS) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE j WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO WORKERS'COMPENSATI NS OF SECTION ]7000F THE LABOR COOE i LL ORT TH COMPLY WITH 1 DATE: ' APPLICANT: I j WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SU&IECI AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (1100,000), IN ADDITION TOTHE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. L CONSTRUCTION LENDING AGENCY i I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE 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 THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDIN CES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION, AND HEREBY AUTHORIZE REPRESS NITA IVES OF THIS COUNTYTO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSP CTION PURP ES. J_ / l PERMITTEE AM PRI ,..✓' D d D SIGNATURE OF PERMITTEE DATE C lr� PRESS FIRMLY APPLICATION PERMIT P/C DATE NUMBER # ISSUETYPE PC)CONST. OCC DATE GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS _ STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM W Garage/Carport WPatio/Dock LL PooVSpa ZRe -Roof 0 Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U_ U W LU LU Z_ a U_ Z Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING 1 MECHANICAL INSPECTION FEE4 ISSUANCE SMTP ENERGY PJC Dq��n�°y CITY OF M " Mr d L ENERGY PERMIT tD t'�� LC�G�' RETENTION FEE: �� PRE -ALT FEE: TOTAL FEES 5 - yL�s^ COMMENTS r RECPT. NO. PAID BYf VALIDATION WHITE— Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File COpy, GReEN—Appacant'S Copy