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Home My WebLink About18612 �.� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES � � � 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS "%.�«�' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE lQ,y��Q'� �QL�� lj�jN� ��— DATEICATION :J-i Z C�L NUMBER f J��Z ��C �/� o ADDRESS_ V � � c� ISSUE `• _� � TYPE OCC APN LO1' TRACT _ DATE y � z� G CONST. GROUP ¢ OWNEFi O " ADDRESS ZONING SETBA o OITY ZIP TEL._ FRONT RW LJ REAR ❑ 0 APPLICANT TEL._ SIDE/SIDE STREET RW ❑ z Q CONTRACTOR � 2 � " E" �lik� SIDE . ❑ O CDDRESSt � ZIP�� TELb�4"' PROPOSED USE CJ�-�r +�0��-� ��7`�0��//Lr F_ � ARCH/ENG � L �� T S �z DESIGNER ._____—___—_ --.- NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TFL._ � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFWADD/REM O p I MEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FFOM THE CONTRACTORS L'- Gef29B/COfport W CENSELAWFORTHEFOLIOWWGREASON(SEC.70Ji.5BUSMESSANDVWOFESSIONSCp�E:ANYCITVOR (n U COUNTYWHICHFEOl11RESA7ERMITTOCONSTRUCT.ALTER,IM�RCIVE.�EMOLISH.CRREPAIRANYiTRUC- W Pd[IOIDBCk WTURE,PRIOR TO ITS ISSUANCE,AL50 REIX11RE5 THE APPLICAN'FI�R Sl1CH PERMIT TO F'�!E A SIGNED W � STATEMENT THAT HE OR SHE I'i LICENSEO PURSUANT TO TNE PROVISIONS�F!HE CONTRACTORS L!- .� CENSELAW(CHAPTERB�CAMMENCINGWITNSECTIONlo00)OFDIVISION30FTNEBUSINESSANDPRO- LL' POOUSPB FE5910NSCODE)ORTIiATHEOR5HEI5EXEMPTTHcqEFROMANDTH[BASISFORTHEALLEGEDEXEMV- � � TION.ANYVIOLATIONOFSEGTIOIv]031.SBYANYA�PIICANTFORAPERMITSU9JECTS'fHEAPVLICAfJTTO Z Re-Rooi � AGIVIL PENAITV OF NOT MORE THAN FIVE HUNDRED DOLURS(SSaD))'. ' Q 71,ASOVJNEROFTMEPROPER�Y,ORMYEMPLOYEESWiTHWAGE5A51HEIP50LECOMPENSAfiON, � Commercial Z WIIL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE!SEC.704d,8U�.1� J NESS AND PROFESSIONS CODE::THE CDN7RACTOHS L��CENSE LAW OOeS NO�APPLV TO AN OWNER OF � PROPERTVWHOBLIILOSORIMPFOVESTHEREON,ANDWHODOESSUCHWORKHIMSEIFORHERSELFOR � ' �� ' � THROUGHHISORHEROWNEMPLOVEES,PROVIDE�ThATSUCHIMPROVEMENTSARENOTINTENDF.�DR � ��r y3.� w OFFEREOfORSALE.IF,HOWEVERTMEBUILDINGORIAIPROVEMENTISSOLOWITHINONEVEAROFCOAIPLE- / TC � TION,THE OWNER�BVILDER WII1 HAVE THE BVRDEN OF PROVING:HAT HE OR SHE DID NOT BUILD OR Z IMPROYE FOfl iHE PUflPOSE OF'SALE). _ �71,FSOWNENOFTMEFROPERTY,AMEXGLJSIYEIYGONTRACTINGWf�HLICENSEDCONTRACTORS � TO CANSTRUCi TME PRQIECT(SEC.]061,BUSINESS AND PROFESSIONS CODE:TME GONTR/GTORS LI- V81U8t10� O � ADJ.AREA W CENSEUWDOESNOTA7PLVT�OANOWNEROFAPROPERTVWHOdU0.D50HIMVROVESTMEREON,ANO = WFiOCONTRACTSFORSUCHPFIOJECTSWITHACONTRACTOA(5)IICENSEDPURSUANTIOTHECANTRAC- QUANTITV DESCRIPTION FEE ~ TOflSUCENSELAW.). Y — ` _� j � ¢ ❑I AA1 E%EMPT UN�ER SFC. B.A PC.FOF THIS PEASON Q W G �+ i {�{ �,/ � �C/G � U � -----.___.___...__. � � � DATE OWNEF F" � Z — U w � LICENSED CONTRACTORS DECLARATION W � I HEFlEBV AFFIRM UNDER PENN_TV OF PERJURY'HAT I AM LICENSED UNDER PROViSIDNS OF CHAPTER � d 9(COMMENCING WITH SECTIOM 7000�OF DIVISION 3 0F THE BUSINESS AND PPOFESSiONS CODE,AND Z X AIV LICENSE IS M FULL FOFCE AND EFFECT. w Q „ � m � UCENSE CL4G, ��__ LIG.NQ. � � � ', �� J V DATE v ��_ CONTRACTOF � .�– d w a�. WORI<ERS'COMPE�iSATION DECLARATION � = a � U � IHEREBYAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWING�ECIARATIONS' Z I Q � IMAVEANOWILLMPINTAINFGERTIFICATEOFCANSENTiOSEIF�INSUREFORWORKERS' _ Z CAMPENSATION,AS PROVIDED BV SECTION J7000F THE LABOfi CWE,FOH THE PEAFORMANCE U ¢ OFTHE WORK FOR WHICN THIS DERMIT IS ISSUED. � , � i w �I HAVEAN�WILLMAINTAIN WOflKERS'COMPENSATION IM1SUFANCE,AS REQUIRED BV SECT��ON '� Q 3]0o OF TME LABOR CODE,FOR THE PEfiFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS � ' -{�� I ISSUED.NV WORKER-'�O ENSATION INSUfiANCE GARFIER AN POLICV NUMBER ARE CONSTRUCTION : J j cnaaiEa ��. _ PLAN REVIEW � Z POLICYNUMBER_._L� ELECTRIC ��I� ¢ �r�+iss[craNNEmraTeEo�r.r�ErEoocn+EaEw,�risror,auEi-uraaEooaisns�siro)oatEss�. PLUMBING p — w MECHANICAL Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS�SSUEO.I Lj SHALLNOTEMPLOYAMVPERSONINANV MANNERSOASTOBECOMESU6JECTTO�HE � WORKERS'COMPENSATIONIAWSOFCALIFOflNIA,ANDAGREETHATIFISHOUlDBECOME INSi'ECTIONFEE � SUBJECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SEC'ION 3700 OF THE LABOP CODe.I SHALL FORTHVVITH COMPLV WiTH THOSE PROVISIQNS. t ISSUANCE � �.� ._\ L; � �� CL � SMIP ...---- � � DATE:� APPLICANT — w ENERGY PiC J WARNING:FAILURE TO SECURI:WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL BE — J � SlI9JECTAN'FMVLOVERTOCRIMINALPENALTIESANDCIVILFINESUP100NEMUNDREDTHOVSAND ENERGYPERMIT DOILARS(flao,000).IN A�DITION TOTHE COST OF COMPENSATION.DAMAGES AS PROVIDEO FOR IN J SECTION 31ae OF THE LABOR CODE,IM1TEFEST,AN�ATTORNEY'S FEES. RETENTION FEE: � i � CONSTRUCTION LENDWG AGENCY PREALT FEE: � _ O � I NFPEAV AFFIqM UNDER PENALTY OF PERJURV THAT THEFE IS A CONSTRUCTION_ENDING AGENCV � Ff)q THE PFRFORMANCE OF TNE WOF.K FOR WHICH THI$PERMIT IS ISSUED�SEC.]09],CIV.C.). Z W � 2 LENDEN'S NAMe _ _ � H LENDEfl'SADOliGSS � I GERTIFV iHAi I HAVE REAO THIS APP'JCATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT TOTAL FEES � ��'/�' w I AGREE i0 COMPLY WITH ALL CITY AND COUNTV ORDINANCES AND STATE LAWS HELATING TO BUILOING � � ��,� � ,. � � CONSTRUCTInNANOHEREBVAUTHORIZEREPRESENTATNE50FTHISCOUNTVTOEMFRUPUNTHE Z ABOVE MENtIONED GROP RT'!FOR Iy57EciioN 7uavo5E5. COMMENTS --� \ � .. :..�;� � `J t,i-1 _ u ` v L!��t , � — � m PERMiTTEENA/AE(PRINTj / � -t�_`� `" -�yl-�_�G L � si TUAe oF reRMmee �. oATE RECPT.NO. PAID BY � VALIDATION _ ~ WHITE—Depariment Copy,YELLOW—Finance Copy,PINK—Assesso�Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy �_ �� .F, •� , , 5 � � :��a _ p° � � � � � "' r � � e �� * � ' � �� i _ , .. . __ . � � :��. �� . �/77"� �.� ° _ __ .,,. � _ __ _, . �=`�'�� _ _ _ _ _ __ . , __ _ _ _ __ , , _ _. _._ _, ..__ _ . _.. _ _ __ _ _ _ . _ �m �� ':. � ' ,�- „� �;�' � � � �� __ _ _ _ � � � e� � a � �' } � „, ,, , ,��.t,r� . ii � � �� , �� a� �— � -� — I!y'j �°, .;. . ,�� ' _ . _ _ aP;�} _ __ _ �, U1,1�III�D B,11S i 0 0 JOBSITE �Q�� 5�f�� + b ADDRESS APN LOT'TRACT OWNER ADDRESS CITY ZIP TEL._ APPLICANT TEL. CONTRACTOR�z� �" �T�e� ADDRESS 1 ZIP��TEL.b�� 'P CITY't� 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,CR REPAIR ANY STRUC- TURE,PRK)R TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SVCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE I:S LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSELAW(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 E%EMP- TION.ANV VIOLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SVBJECTS'fHF APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f 500)): ^ I,AS OWNER OF THE PROPER N,OR MV EMPLOYEES W iTH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE !iTRUCTURE 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, HOWEVE R THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE V EAR OF COMPLE- TION,THE OWNER�BUILDER WII1 HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOP THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WfTH LICENSED CONTRACTORS TO CONSTRUCTTHE PROJECT(SEC. 70d1, BUSINESS AND PROFESSIONS CODE:THE. CONTRACTORS LI- CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY W HO d'JII.DS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PFIOJECTS W ITH A CONTRACTOR(S) 1 ICENSED PURSUANT 1'0 THE CONTRAC- TORS LICENSE LAW.). ^ I AM E%EMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENAI_N OF PERJURY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSiONS CODE,AND MV LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLA LIC. N0. DATE V��?�-CONTRACTOR,'_ WORI{ERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BV 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 BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS RA N POLICY NUMBER ARE: ISSUED. MV WORKERS'0 ENSATION INSURANCE CARRI E f CARRIER�, '�"��v POLICY NUMBER . L�9 ,��h-CST-�p�-LS jam/ ' L / PERMIT IS FOR ONE HUNDRED DOLLARS(f100)OH LESS). (IRIS SECTION NEED NOT BE OJMRETED OF THE I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.I SHALL FOgRTHWITH COMPLY WITH T OSE PROVISIONS .t, APPLICANT��t � e t' L �I �-c DATE: L WARNING: FAILURE TO SECURE: WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN'EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOVSAND DOLLARS(f 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 I5 A CONSTRUCTION LENDING AGENCY FOR THE PE RFORMANGE OF THE WOFK FOR WHICH THIS PERMIT IS ISSIJED(SEC. 309],CI V. C.). LENDER'S NAM LENDER'S ADDRESS I GERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I 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 NTIONED PROP RT�! FOR IySPECTION PURPOSES. ABOVE--M-E \ \vurne �Jt,i-1 '_u PERMITTEE NAME(PRINT) 1 BI TUBE OF PERMITTEE�DATE Q LL 0 w z 0 0 z 0 Q w 0 z w cn rn 2 0 W U Z W U H 0 Z W D Z W Q W 2 F-- ]C Q LL Z 0 fl X W V UJ Z D J Z Q W Z 0 J J LL } J W d 0 Z W 2 W d Z 0 CITY OF DIAMOND BAR DEPARTME'N'T OF CONA/tUNI"fY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY WHITE-Department Copy,YELLOW-Finance Copy,PINK-ASSesso! Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy