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Home My WebLink About18228 (11) �� CITY OF DIAMOND BAR �"'"r T I �-W� DEPARTMENT OF COMMUNITY&DEVELOPI�NT SERVICES 21825 E.Copley Drive � (909)860-3195 Fax(909)861-3117 PRESS "%»�� " BUILDING PERMIT APPLICATION FIRMLY QJOBSITE E�&�'� ��p,,// L� DATE CATION �,, �5.� PU 8 R � P/C a ADDRESS� d t//VO� [/ # � ISSUE TYPE OCC APN L.OT _ TRACT DATE CONST. GROUP p OWNER o ADDRESS _ ZONING SETBACKS z CITY _ ZIP TEL FRONT Ry� � � APPLICANT _ TEL. REAR ❑_ z - SIDE/SIDE STREET RW []_ Q CONTRACTO / G SIDE �� ADDRESS�' AG 3 � CITY ��' SC�! ZIPq/�I'?3 TEL. ?�• �f�q� PROPOSED USE o ARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DECLAFATION SFR/ADD/REM O Q I HEREBY AFFIRM UN[IER PENALTV OF PERJL'RY THAT I AM E%EMPT FROIA 7NE CONTRACTORS LI- G8f2JQ/C8fP01S W CENSELAWFORTHEFOLLOWINC.FEASON�SEC.]031.SBUSINESSANDPROGESSIONSCODE:AN�CITVOR (f� U COUNTVWHICHREOUIRESI\PERMITTOCANSTRUCT,AL7EF,IMPROVE,DEMOLISH,ORREPAIRANYSTiiUC� wTURE,PRIOfl TO ITS ISSUANCE,ALSO REQUIRES THc APPLICANT FOR SUCH PERMIT 70 FIIE A SIGNED w Patio/�eck � STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRAGTORS L'.- � �i, � GENSE LAW(CHAPTER e(COMMENCING WITH SEGTION]000)OF�IVISION 3 OF THE 6USINESS AND PRO- POOUSPB FESSIONSCODE)ORTMATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (� U TION.ANVVIOLATIONOFSECTION7031.5BYANVAPPLICANTFORAPERMITSUBJECiSTHEAPPLICANTTO Z R0-R001 I � ACIVILVENALTVOFNOTMORETHANFIVEHUNDREDDOLLAR51f500).): � �I,ASOWNEROFTHEPROPERN,OFMYEMGLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 Commercial z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOF SALE(SEC.7oaa,BUSI- J � NESS PND PROFESSIONS CODE:THE CONTRACTORS LICENSE�AW OOES NOT APPLV TD AN OWNER OF � PROPERTV WHO BUILOS OR IMPROVES THEREON,AND WHO�OES SUCH WORK HIMSELF Oq HERSELF OR wTHROVGH HIS OR HER OWM EMFLOYEES,PPOYIDED THAT SUCH IMPROVEMENTS ARE I�T INTENDED OR m Q OFFEflEOFORSALE.IF,HOW'EVEfl,THEBUILDINGORIMPqOVEMENTI550LDWITHINONEYEAROFCOMPLE Z TION,THE OWNER-BUILDEFI WILL NAVE THE 9URDEN OF PROVING THAT HE OR SHE DIO NOT BUILD OR � IMPqOVEFORTMEPURPOSEOFSALE). w ❑I,ASOWNEROFTHEPROPERTY,AME%CLUSNELVCONTRACTINGWITHLICENSEDCONTRACTORS � TD CANSTRUCT'HE PROJfCT(SEC.7044,BUSiNE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- VeIUeHOn ADJ.AREA W CENSELAWDOESNOTAPR,.VTOANOWNEROFAPROPERTYWHOBl11lDSORIMPROVESTHEREON.AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TDRS LICENSE LAW). O ❑1 AM EXEMPT UNOEfi SEC. B.8 P.C.FOR THIS REASON Q � U � � OATE aWNER_ H Z U � LICENSED CONTRACTORS DECIARATION W ¢ � 1 HEFEBV AFFIRM UNOER PENALTV OF PEFJURV THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER � d 9�COMMENCINGWITHSEC'fION]000)OFONISIONJOFTHEBUSINESSANDPROFESSIONSCODE,AND Z X MV LICENSE IS IN FULL FOFCE AND EFFECT � LICENSE CLASS��{d� 2 � LIC.NO. J 0{,L� ) � -_� ~ �ATE `�Z {l'•"" � 2- CONTRACTOR �� d W � { � WORKERS'COMPENSATION DECLARATION a 2 � vJ� � � � I HEflEBVAFFIflM UNDER PLNALTY DF PERJURV ONEOF THE PoLLOWING DEGLHRATIONS�. Z Z IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' ¢ 2 ¢ COMPENSATION.A,�PPOVIDED BY SEC710N 3]00 OF THE LAPOR CO�F,FOR THE PERFORMANCE U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � Qw _I HAVE AND WILL MiJNTqIN WORKERS'COM�ENSATION INSUHANGE,AS FEOUIRE�9Y SECTION 3700 0F THE LPBOP COOE,FOF THE PEFFORNANCE OF THE WORK FOR WHICH THIS PERMIT IS J ISSUEO.MV WORKERS'CAMPENSATION INSUFANCE CARRIER AND POLICY Nl1MBFRARE� CONSTRUCTION �.� j CARRIER_��I�-I� /'JAJYJ PLANREVIEW � POLICYNUMBEA_ �? `[�� L2 ELECTRIC Z Q � (iHISSEC110NNEm'VOTBEWMPLEfEDOFTHEPEFIWTISfOHONEHUPD(iEDDIX1AR5(510J)ORLESSG PLUMBING _ __ W Z I CEFiTIFY THAT IN THE PEFFOFMANCE OF THE WORK FOF WHICH THIS?ERMIT'�S ISSUED,I MECHANICAL 1 (�S SHALL NOT EMPLD\'ANV GERSON IN:1NV MANNER SO AS TO BECOME S'JBJECTTO THE Uj WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOUL�BECOME INSPECTION FEE �- SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION3]o00FTIiELA80R � CODE,I SHALL FOR�HWITM COMPLV WITH THOSE PROVISIONS. ISSUANCE � T p �ATE:�_ APPLICANT: �' _ _ _ SMIP . _ W J WARNING FAILURETO SECUpE WORKERS'COMPENSATION COV RAG 5 UNLAWFUL,AND SHALLBE ENERGY P/C __ � SU&IECTANEMPLOVERTOCRIMINALPENAlT1E5ANDCIVILFWESUPTOONEHUNOR[�THOVSAND ENERGVPERMIT OOLLARS(5100,000�,IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SEGTION3T080FTHELABORGODE,MTEREST,ANDATTORNEV'SFEES. ¢ RETENTION FEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBVAFFIRMUNDERPINALTVOFPERJURVTHATTHEREISACONSTRLICTIONLENDINGAGENCY FOR THE PEPFORMANCE O'�=THE WORH FOR W41CH THIS GCRMIT IS ISSUCD(SEC.�09],CIV C.). ---- Z W - ? LEN�ER'S NAME � F- LENOER'SADDRE55 � ¢ ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOFMATIONISCORRECT TOTAL FEES ) d I AGPEE 70 COMPLV WITH P.LL CITV AND COUNTV ORDINANCES AND STATE LAWS R[LATNG TO 6UILDING � CONSTRUCTION,AN�HEflEBVAUTHORIZEREPflESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONED PROPERTY FOR INSPEGTION PUFPOSES. COMMENTS � � J � _.__...__ m PERMITTEE NHME(P NT) .._._..___...__...._-.- � � Q Z � SIGNATURE PERMITT �AT'c = RECPT.NQ PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—ApplicanYs Copy a. � r .�� , � � � ��, �� ,�w.,; ��•��, v� .. . ° �� ' � . :` -��a�k�a�� s w �� ; � '��:. . �� , y ��.�.., •.. �� . - ��_ � , . ... .. F..7�:3 3.s, ..e '��. 7. .'s�°,�'� �°� . n x,. . � .... . � . . J �.. . .. .. ._. .. .. .. . ... .. . L � . .. . ��. .. . . .. . �. . . �. . . . . � ...� . ... .... . ._.�. . .... ...... ,. . ._ ... . . . . .. .. . ... .. . ... .... . . ... . � �, ... .... .. .�. a ' _ . � � � � F� � - .,. , ,:� �r.z�z,F . ��=�5•!' t7UC-K �--k�G� �'-Roµ LeJ1tL4Ci C-'� ��'- 7�t Z�°Z __ � " � � �u .: � , i� ��pa s . _ �i t��, �ii �5 +.i '��. �^ _ �� 6 E ��., .... . _ . . _. ..... ... . .. ... . . _... . .. . . .. .. ... ... . '. ��,�.3 .__ ._ _- .. � ," ,��.� m j I°.. ...... ....... . ... .. .. ..... .. .... .... .. . .... . - �� -j.. g ' . .. . . .... .. . . . ._.. . . �� .a ' e � � � . _ . ' .`�..�� e' `. . . ... ... ... ...... ... ... .. . . ...... .... .... .. .._ _. . _. . .... ... .. . .... .. . elum-s i JOBSITE ADDRESS End �- rr- b�n�//�� ADDRESS APN L.OT_TRACT OWNER ADDRESS CITY ZIP TEL. APPLICANT TEL. CONTRACTO ADDRESS'AG 3 CITY s aL M! ZIP TEL. -16, k2r-49 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 REOUIRESAPERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIRANY 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 THEREFROM 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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): D I,AS 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(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 FOR SALE. IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE- 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 EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSELAW DOES NOT APP,.Y TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). C I AM EXEMPT UNDER SEC. B.&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 THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLASS�{d 2 LIC. N0, DATE L^2 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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I 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'COOMP ENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: PE CARRIER JI�-/L/XoJYJ POLICY NUMBER J2�G�2 L.Z (THIS SECTION NEED WOT 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'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 CO V RAG S UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),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 A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE 0=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 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. I is 4 ci AIII PERMITTEE NAME(P NT) SIGNATURE PERMITT DATE CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY APPLICATION PERMIT P/C DATE UMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^_ SIDE PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SCI- FT FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM U) Garage/Carport w Patio/Deck L L.I LL Pool/Spa 0 Re-Roof Z Commercial Ib Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U W W a Z M J d U 2 JM Z 15 13 Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT. N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PIN P Lx-TS•!'t7)c-'C--i 2oK Ge/1tL4�c-, iv-- 1-1 Z�c