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Home My WebLink About15113 (44)s� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 8603195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS ��L APN LOT TRACT OWNER ''TAA-CMf 11124-0 ADD ESS CITY �ZIP TEL32a APPLICANT TEL CONTRACTOR- ADDRESS ONTRACTORADDR SS B CITY TELdi%T ±& ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U CENSE UW FOR THE FOLLOWING REASON (SEG 7031.6 BUSINESS AND PROFESSIONS OODE:ANYCITY OR COUNTYWRICH REOUIRESA PERMrTTO CONSTRUCT.ALTER IMPROVE. DEMOLISH. REPAIRANY STRl1G TUBE, 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 PROVISKWS OF THE CONTRACTORS LF DENSE LAW (QIAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE SUSINESS AND PRD FESSNONS CODE) OR THATHE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP• TION. ANY VIOLATION OF SECTION 7071.6 BYA Y APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACNL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS [SSW).): O L AS OWNEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WOW, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUADS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR MER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ME NOT INTENDED OR OFFERED FORSALE IF. HOWEVER. THE BULDNOOR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE O L AS OLLNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC, 7044- BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - DENSE UW DOES NOTAPPLY TO AN OWTNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WINO CONTRACTS FOR SUCH PROJECTS VATH A CONTMCTOR(S) LICENSED PURSUANT TO THE COHTRAC- TORs LICENSE LAW.)_ O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HERESYAF V FIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULL FORCEAND EFFECT. LICENSE CLASS �� LIC. NO. �.7 ,/ CL5� DATE &=4 CONTRACTOR WORKER5 COMPENSATION DECLARATION 1 HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MANTAN ACERTIFICATE OF CONSENT TO SELFINSURE FOR WORKERS' COMPENSATION, AS PROVIDED SYSECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. —I HAVEAHD WILL MANTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIRED BY SECTION 1700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WO Its COMPENSATION IN�SURANCEE?CAR�MLEER AND POLICY NUMBER ARE: CARRIER IZ'iL� POLICYNUMBER Ls91f� �O�(-�CC1 Mw KWIDN ra®NOTBE OattiETED OFTH E KAM IS FDR ONE HUNDRED DOL1Ata (Sloo)ORLM% I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALLNOT EMPLOY ANY PERSON N ANY MANNER SOAS TO BECOME SUBJECT TOTHE WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME SUBJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR CGDE'.. rII SHALL, FORTIHWTH COMw IaarnA6e*rev s. DATE: �U APPLIGAL-- I WANING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL 9UB.IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE /KINDRED THOUSAND DOLLARS (3100.000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN i SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY i 1 OR THE AFFIRM MANCE PENALTY OF K Fog W THAT THERE IS ACONSUED (SEC LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ($EC. 3007, CIV. C.). i LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. IO I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE#AENfDNED PROPERTY FOR INSPECTION PURPOSES. or PERMITTEE NAME SIGNATURE OF PERMITTEE DATE �0/3opo/ PRESS FIRMLY APPLICATI N PERMIT/' P/C DATE NUMBER I ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS RW ❑ REAR ❑ LjFRONT SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED US NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION SFR(ADD/REM GaragaMarport W PalfolDeck LI- PooUSpa - ZRe -Root OJ . Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J ¢ U cc U W J W Z >✓s cc J CL J U 2 2 U ULj 2 {�T w A. TIT K1 CONSTRUCTION f1 PLAN REVIEW ELECTRIC PLUMBING CITY UI. 1!Ifi1V1VLN LLA. MECHANICAL RTHT TING ANI) �:'sl'� L INSPECTION FEE —7 �— ISSUANCE VS SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES 5 COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department COW. YELLOW—finance Copy, PINK—A3sessor Copy, GOLDENROD—Elle GOpy, GRLLN—ApplKxnra L:opy