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Home My WebLink About18592 � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNTfY&bEVELOPMENT SERVICES 21825 E.Copley Drive N (909)&60-3195 Fax(909)861-3117 PRESS ��;��~ BUILDING PERMIT APPLICATION ��, ,� , FIRMLY � JOBSITE ��,r� n ° ¢ ADDRESS_�/ �f � /1 APPLICATIO �fa� P RMIT ��/� p/C o -- — DATE NUMBER�S1�� f�� ISSUE i TYPE OCC APN--y� LOT_ T�RA�C/��, � [ 11�f� ClV'Yl�—S ��_ DATE ! U CONST. GROUP p OWNER o ADDRESS �_ ZONING SETBACKS FRONT z CITY ZIP 7E . � ." �J RW ❑ � APPLICANT TEL.___ REAR � z SIDE/SIDE STREET Ryy_ J Q CONTRACTOR � SIDE L ADDRESS r ,p. + � CI7Y ZIP TEL '� PROPOSED USE � �9 1 �� d� (Y oARCH/ENG( z DESIGNER� w -- NO.DWEL. (� NO. � NO. a ADDRESS � �n UNITS / STORIES BEDROOMS � CITY ZIP__ TFL.-- — � DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION p SFR/ADD/REM � I MEftEBV AFFIRM UNDER PENALTV OF PERJURV i HAT 1 AM FXEMPI FHOM THE CONTqACTOqS LI� GOIaJe/CafpOft W GENSEUWFORTHEFOLLOWINGREFSON(SEC.70.3t.58U51NESSANDFqOFESSIONSrODE:ANVCITYOR (n U COUNTVWHICMREQUIRESAPEFMITTOCONSTRUCT,ALTEF.IMPROVE,DEMOIISM,CRFEPAIRANViTRl1C- w TURE,PRIOR 70ITS ISSUANCE:�,n150 REOUIFES iHE APPLICAM FOR SUCH PEPMIT TO�ILE A SiGNEO w Patio/Deck Lc STATEMENT THAT HE OR SHE IS LICENSED PL1RSlIANT TO THE PROVISIONS OF THF CONTRACTORS LI- � CENSE LAW(CHAPTE4i B(COMMENGNG WITH SECrIOM1 1000)OF OIVISION 3(�F THE BUSINF55 AND PRO- LL PDOVSpO O FESSIONSCADE)OqTHATHEGRSHEISENEMPTTH�REFROMAM1DTHEBA515FORTHEALIECEDE%EMY- � /��y U TION.ANVVIOLATIONOFSECTIt]N]031.SBYANVAPPLICAN,-FORAPERMITSJ9JEC�5"MEAPPLICFNTTO Z Re-Roof �/ (/ � A CML PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(I500))�. Z ❑I,ASONTIEROFTHEPROVER�YORMVEMPLOVEESWITMWHGESASIHEIR50LEGOMPENSATiON, ❑ Commercial WILL DO THE WORK,ANO TME iTRU(:TURE IS NOl IN i ENDED OR OFFERED FON SALE!SEC.70dd,BU�I- J � NE55 ANO PflOFESSIONS CADE::THE CONTRACTORS LICENSE LAW DOcS NO�APPiV TO AN OWNER OF PROFEFTYWHOBUILDSORIMF'ROVESTHEREON,ANDWHO�OESSl1CHWORKHIMSELFORHEHSELFOF � wTHROUGM HIS OR HER OWN EMPIOVEES,PROVIDED THAT SUCH iMPROVEMENTSARE NOt INTENDEOOR m Q OFFEAE�FORSALE.IF.HOWEVER,THEBLIILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOIAPLE- Z TION,THE OWNER�BUILDER WI1 HAVE THE BURDFN OF PROVING:HA7 HE OR SHE DIO h0T BUILD OH � IMPROVE FOF THE PURPOSE 0=SALE). w ❑I,AS OWNER OF THE PiUJPERTV AM EXCLU5IVLLY CONTRACTIN3 WITH LICENSE�CONTRACTORS [t TO CONSTRUCi THE PRQIECT(SEC.]004,BUSINE55 AND PROFESSIONS CODE:THF GONTRpCTORS LI- V81U2�1Df1 � ADJ.AREA W CENSE LAW DOES NOTAPPLY TDAN OWNER OF A PROPER'Y WMO dJII.n50R IMPROVES TNEREON,AND — WHOCONTRAGTS FOF SUCH PFOJECTS WITI+ACONTRAGTOR�3)LICEM1SCD PUflSUANT TOTHE CONTRAF ~ Toas uceNSE�nw.�. �UANTITY DESCRIPTION FEE Y Q ❑1 AM EXEMPT UN�ER SFC.._ _,_ B.8 P.C.FOR THIS REASON Q � U � -_._--- — [C — DATE OwrvGH H Z U � LICENSED CONTRACTORS DECLARATION W ¢ � I HEREBYNFFlFM UNOEq f'ENA;TY OF PERJURV THAT I AM IICENSED�N�ER PROVISIONS CF CHAPTEF U. . d 9(COMMENCING WITH SECTtON 7000)OF DIVISION 30F THE BUSINESS AND PP.OFESSiONS CODE.AND Z �X MYUCENSE IS IN FULL/FORCE A EFFECT. � � LICENSE C SS,�'/V--/},��—�/ _ LIG.NO. • �� S � ~ DATE__��r��_f.r�4�•�� _ GONTRACTO�.� �•`G+ n. U W � WORKERS'COMPENSATION DECLARATION Q � I HEREBYAFFIRM UNDER PENAI.TV OF PERJIJRY ONE OF THE FOLLOWING�ECLARATIONS: U � Z � 1 HAVE AND WILL MAINTr11N A CERTIFICA7E OF CONSENT TO SELF�'�NSURE FOR WOflKERS' a Z MPENSATION.AS PROVIDEO BY SEGTION 3��0 fJF THE LA90R COOE,FOR THE PERFORMANCE U Q OF THE WORK FOR WHI�H THIS PERMIi IS ISSUED. � w 1 HAVE AND W1LL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RECUIRED BV 5[CTION ,/�/� 4Q 3"!0o OF THE LABOR Cd�E,FOR THE PERFORMANCE OF TNE WORK FOR WHICMTHIS PERMIT IS / A� ) y� ISSUED.MV WORKERS GOyy PE��NS TION-M-.S;u�q��GFRRIER AND POLICY NUMBERARE' CONSTRUGTION "�� J j caaaiEa � � !/�U� _ PLAN REVIEW zPoucv NurneEa_�S��_: � .___ ELECTRIC ¢ -- 0 (iHISSECTIONNEmN0T3EQ'JMPLEfEDOFTHEPERA�YTISFOFpJENUf�DAED00llARS(E10J�OfiLESS; PLUMBING W Z I GERTIFv THAT IN THE PERFORMANCE OF THE WORN FOR WHICH�HIS PEHMIT IS ISSUED.I MECHANICAL C`3 SHALL NGT EMVLOY AN'(PERSON IN ANY MANNER 50 AS TO BECOME SLI9JEfT TO THE -�� — (n WORKERS'COMPENSAI ION LAWS OF CAUFORNIA.AND AGflEE THAT IF I SHOULD BECOME INS:�EGTION FEE � SUBJECTTO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 3]00 OF THE LABOR - --'YT"� � COOE.I SHALL FORTHVr'ITH COMPIY WITH THnSE GROVISIONS. ISSUANCE / O « p DATE: APPLICANT: SMIP _ W -- J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AN�SHALLBc ENERGY P/C J __. � SUBJECTANEMPLOY�RTOCRIMINALPENALTIESAN�CIVILFMESL'P100NEHUNDRE�THOUSqND ENERGYPERMIT � DOILARS(f100,000).IN A�DITIOIV TO THE COST OF COMPENSATION.DAMAGES AS PROVI�F[I FOR IN --- _ __ _, J SECTinN i]OP OF THE LA00R Ci]DE.INTEREST,/.N�ATTOFNEV'S FEES_ � RETENTION FEE: OCt�NSTRUCTION LENDING AGENCY PRE-ALT FEE� __ _ � IHER=BYAFFIRMUNDERPENAI.TVOFGERJURY'HATTHEREISACONSTFUC'IONLENDINGAGENCY � FOR THE PEHFORMANCE OF TH�WOFK FOR WHICH THIS GERMIT IS ISSUED ISEC.3091.CIV C.). -- Z W = LEIvD�N'S AAAAE - � _ _ 1— LEND=R'SADUAESS � w ICERTIFVTHATIHAVEflEADTHISAPPLICATIONANOSTATETHATTMEABOVEWFORMATIONISCORRECT TOTAL FEES ��.� J� � I AGREE TO COMPLV WITH ALL GITY ANC COUNTV OR�IM1ANCES AND STATE lAWS RELATWG TO AUILDING 1 1 � CONSTRUCTION,AND HEREBY P.UTHORiZE REPRES'cNTATIVES OFTHIS COUN'V TO'cNTER UPJN THF V Z ABOV NTION 7ERTV. SPECTION PURPOSES/. COMMENTS � n� / 'V � — m PE EE NAME(PA //�� ///''�^''� � 'Y 2 \t f� V�f.s_ — Uj SIGNATURE OF E ITjFE DATE -'-��- � - � " RECP?.NO. __ PAID BV VALIDATION WHITE—Depariment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�—File Copy,GREEN—AppliCanfs Copy . . . . . . ..:��w' , `�" ff u 6� ?& 6d t�'�ra �'&t�figi�a� �"e v��"�.%.'p � a�c, p�� i . �,� , �' � ' � �, f�e�, . '��.� ., . �"`�� '" ��'�„ ,, E�,�S _ _ , � _ __ __. _ � � ��, r.�. _ __ _ �� ,; �� . — y,�� .. � � �, �� _ _ _ _ �: �� , � � �' ��' � _ _ _ �.. � ,�� ,; ,- s, u � �� _ � , , :�,p : _ _ �' ,- �,i �� `�� '� �,; _ _ � ,: ��, � � . ��,s;� t � � __ _ r��r ` - �� . ,�., ��,�; � �` CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE n��l ADDRESS Iv'c I �IP& APN LOT_TRRA �� OWNER_(: tAA(;/IF!'1�I ADDRESS�(- CITY ZIP TE APPLICANT TEL. CONTRACTOR ADDRESS r CITY ZIP 12*TEL ARCH/ENG/ DESIGNER S ADDRES 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 PERMITTO CONSTRUCT,ALTER. IMPROVE, DEMOLISH,CR REPAIR ANY 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 CR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION,ANY VIOLATION OF SECTION 7031,5 BY ANY APPLICANT FOR A PERMIT SURJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500)) .- 0 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, BUT(- 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 WI-L HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE 0-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- CENSE LAW DOES NOT APPLY TD AN OWNER OF A PROPERTY WHO dUII.DS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW) ^ 1 AM EXEMPT UNDER SEC. B.A PC. 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 FORCES{/rygp)EFFECT �+- LICENSE CLASS-7 b 1 -5 LIC NO Vc? AT 6t D E lONTRACTO A••C+ 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' V MPENSATION.AS PROIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHIC H 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 WORKER ,NCS'COPE CO PEARRI R AND POLICY NUMBER ARE CARRIER POLICY NUMBER li%0-Z fu I TfT (THIS SECTION NEED NOT BE COMPLETED 0 F 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 COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 10 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 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 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 ABOV NTION PERN-SPECTlON PURP�OSEf/S. PE EE NAME(PR'r Y 4'vV SIGNATURE OF E ITjEE DATE WHITE-Department Copy,YELLOW-Finance Copy, PIN '{ 1 PRESS FIRMLY APPLICATIO PERMIT 13A�P/C DATE .Q NUMBER ISSUEi TYPE OCC DATE{ U CONST. GROUP ZONING SETBACKS FRONT RW L REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ PROPOSED USE ++ (y N0. DWEL. '�j N0. N0. UNITS/STORIES BEDROOMS DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM U) Garage/Carport LU Patio/Deck Pool/Spa Z Re-Roof Commercial Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U U W W CO a U Z 2 0 U CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE --- ISSUANCE - SMIP CQ ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES o i 1 2*9 COMMENTS RECPT N0. PAID BV VALIDATION