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Home My WebLink About18537DL1)IDRD 1, CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861.3117 BUILDING PERMIT APPLICATION , L ..TT-... JOBSITE ADDRESS _ �� •� APN LOT --MU TRACT � OWNER k`A'YL-1u/�V ADDRESS CITY ZIP TE APPLICANT TEL. CONTRACTO ADDRE S CITY ZIP TEL/ DESIGNER 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 FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY VMICH REQUIRESAPERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC" TUBE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER 9 SHE WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT TH REFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORAPERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIV_ HUNDRED DOLLARS (SSW0 ).. r71. AS OWNER OF THE PROPERTY, OR MV EMPLOYEES W,TH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70. SUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NO, APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, 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 WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7DAA, BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS LI" CENSE LAW DOES NOT APPLY LOAN OWNER OF A PROPERTY WHO 2UILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CON7RACTOR(S) LICENSED PURSUANT TO THE COWRAC- TORS LICENSE LAW) G I AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM 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 FORC ANplp�yEFFEyCTr. LICENSE C SS ~ r V LIC. NO. DATE 1? 44' CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF 'HE FOLLOWING DECLARATIONS: 1 H E AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO Or FOR WORKERS' PENSATION, AS PROWOED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND MILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI' IS ISSUED. MY WORK Q�M2(� SATIO RANCE�f�)RBIER AND POLICY NUMBER ARE: CARRIER f r� P '/ POLICY NUMBER f J (THIS SECTION PEED NOT 13E COMPLETED OF THE PERMIT IS FOR ONE HUNDRED 00-LARS (SI 00) OR LESST I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANI' PERSON IN ANY MANNER SO AS TO BECOME SUDJECT TO THE j 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 FORTHW TH COMPLY WITH THOSE PROVISIONS. 1 DATE:. APPLICANT: I I WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS (5100.000). IN ADDITION D TO THE COST OF COMPENSATION. DAMAGES AS °ROVED FOR IN 1 SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 3 CONSTRUCTION LENDING AGENCY i I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE ISA CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ;S ISSUED (SEC, 3097, CI'✓. C.). 1 LENDERS NAME LENDERSADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY ANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION, AND HEREBY A.RHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR Ilj ECTION PURPOSES. 5 J PERME (PRI ) C 1 O SIGNATUREO=P MITT • DATE C PRESS FIRMLY APPLICA PERMIT 1 ` P/C DATE NUMBER # • ISSUE ,"� TYPE OCC DATE ' CONST, GROUP ZONING SETBACKS FRONT RW ❑ _ REAR ❑ _ SIDE/SIDE STREET RW fl SIDE ❑ _ _ _ PROPOSED USE NO, DWEL.N UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFRIADD/REM U) Garage/Carport WPatio/Deck LL PODYSpa Z Re -Root 0 Commercial m Valuation _ ADJ.AREA QUANTITY DESCRIPTION FEE _J Q -- U 2 L— U LU J W CD 2 Fo - a J Q U_ Z Q 2 W Y CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL ... INSPECTION FEE _. l ISSUANCE iii LI SMIP ENERGY P/C ENERGY PERMIT I RETENTION FEE: I L PRE -ALT FEE'. TOTAL FEES COMMENTS ._. RECPT NO. _. - PAID BY �' VALIDATION!' WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor UOPy, UULUCNNU Ile I,OPy, UnCMrV—Appncems L,VPY 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 F ADDRESS- APN LOT TRACT OWNER ADDRESS CITY ZIP TE , APPLICANT TEL. CONTRALTO ADDRE S CITY ZIP TEtj I ""It 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 REQUIRESA PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC. TURF, 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 THERE FROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SURJEC TS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($5W)) ^ I, AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS IHEIR 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 WITHIN 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 CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S11.ICENSED PURSUANT 10 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 FORC A FFECT r G 7A V LICENSE C SS LIC NO, DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS I H E AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF.INSURE FOR WORKERS' MPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED. -VI 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 WORK SATIO F RANCE C,-4RRIER AND POLICY NUMBER ARE "rI(J "1/SII CARRIER POLICY NUMBER • _.( II—Y0 (THIS SECTION NEED NOT 13E 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 AN" PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, ANO AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHW TH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT 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 ($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. CONSTRUCTION LENDING AGENCY 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 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 AJTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR IPA ECTION PURPOSES. PERM E E (PRI SIGNAiUREOF PE MITT i DATE APPLICA PERMIT + P/C DATE J NUMBER ISSUE TYPE OCC w DATE ° CONST GROUP ZONING SETBACKS FRONT RW ^ REAR F 1 SIDE/SIDE STREET RW ^ SIDE ^ PROPOSED USE III)n NO. DWEL. N UNITS 4 STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION 4 SFR/ADD/REM W Garage/Carport W Patio/Deck t LL PooVSpa 0 Re -Root Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE w W Z EQ IL Q Q 2 U W 15C— J s - CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. N05PAID BY TI) VALIDATION WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy 7