HomeMy WebLinkAbout18595 CITY OF DIAMOND BAR
��'`� DEPARTIv1ENT OF CO[vIIvtUNTCY&DEVELOPMENT SERVICES
21825 E.Copley Urive
(909)&60-3195 Fax(409)861-3117 , i PRESS
'��� BUILDING PERMIT APPLICATION -� � FIRMLY
JOBSITE �j APPLICATION (� cy� PERMIT ( P/C
o ADDRESS__ 40 __ �'�� DATE D[�•C'L�� NUMBER� #
o ISSUE r] i � TYPE OCC
°r APN—�r- LOT �T{�AC/�T � ,,��,,/� __ DATE___ �� � CONST. GROUP
p OWNFR ( iiW�/�TUZLiI'J C//Tf�--T' i�V�'T
� ADDRESS ZONING SETBACKS
� FRONT RW ❑
oCITY ZIP_ 7E � REAR ❑
o APPLICANT TEL._____ ` SIDFJSIDE STREET RW rl
¢ I SIDE ❑
mQ CONTRACTOR –
� ADDRE ~ +�1C%�� PROPOSED USE W C
� CITY ZIP "�TEL/C�,��}`'"' ' ' '�
w ARCH/ENG/ L ��
z DESIGNER_ -- NO.DWEL. ~f NO. ( NO.
a ADDRESS_ UNITS � STOAIES f BEDROOMS �
� CITY ZIP __ TFL_.
� DESGRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
�
� OWNEF-BUILDER DECLARATION SFR�ADD/REM
O
� I HEREBY AfFlRM UNDEfi PENALTV OF PEFJURY'4AT I AM F.%EMPT FROM THE GONTRAGTOqS LI� � Garage/Carport
W CENSEUWFCRTNEFOLLOWMGFEASON(SEC."fC31.50USINE55PNOViOFE551ONSCOOE�.ANYCITYOR
� GOUNTVWHIGHREOUIRESAPERMIT�OGONSTRUCT,ALTcR,IMPFOVt.DEMbUSH,CRREPAIRANViTRUC- W pati0/DBCk
w TURE,PRIOR TO ITS ISSUANCE,AL50 Re�UIRES TNE APPLICANT FOR SUCH PEflM1T TO FILE A SIGNE� w
� STATEMENT THAT HE Oft SHE IS LICENSED PURSUA�IT TO TME?ROVISIONS bF T1E CONTRACTORS LI- �y pooUS e
� CENSE LAW�CHAPTER 9(COMMENCING WiTH SECrION 7ooa;OF�'Vicic�N;�F THE BUSiNESS AND Pa0- P
O FESSIONSCO�E'iORTMATHEORSHEiSEXEMPTTN�REFROMANOTHEOASISFORTHEP.LLEGEOEXEM'r'- �
V TION.ANYVIOLATIDNOFSECTION'/0]1.SBYANYA7PLICAN�FORAPERMITSU9JE(:!5"Ii1=APGLICAVTTO Z Re-Roof
� A CIVIL PENALTV OF N01 MORF THAM FIVE HUNDFlEO DO�_LARS(S5o0))�
O ❑I,ASOWNEROFTHEPFlOPEF�V,ORMYcMPLOVEE$W�THWAGE54JiHE'�950lECliM�ENcq;iUN, Q COIT1R1CfCl21
Z WILI DO THE WORK,AND TNE STFUL'TURE i5 NOT IN iENI?[�OH OFFEFEU FOH SALE!SEC.704d,BU"�I� J
� NESS AND PROFESSIONS GODE:THE GONTRAGTORS IICENSE LAW OOc'S NO:APPi�TO Alv GWNER OF �
. PROPERTYWriV�'JfLDSOR�MPflOVESTHEREO�.ANDWNODOE55l�CHWOftKH'�MSEIFORHEr�SE�,F�H
� Q TNFiVUGM HIS OH HEFOWN EMPLOVEES,7ROVIDED THAT SUCH IMPROVEMENiSARE NOT INTCNDEDOR L�
w OFFEREDFORSPLE.IF,HOWEVER7HEBUIL�INGOFIMPROVEMENTiSSOtD'NITHINONfvEAROfCO�APLE-
� TION,THE OWNER�BUILDER WiLL MAVE 7HE BURDEN OF PROVINC'HA1 HE OR SHE�IO NOT BVILD oN
Z IMVROVEFORTHEPUPPOSEOFSAIE).
= rl1ASOWNEROFTHEPFOPEFTY,AMEXC�USIVELYCC�NTRACTINGWITHLICENSE�CONTRACTOPS -
� TO CANSTRUCT 7HE�ROJECT(SEC.]ON,BJSINESS AND PROFESSIONS CODE.THF CONTRALTORS LI- V8Il12tI0f1 ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANOWNEROFAPRO°EFTVWMOdVII.D50FIMPROVE5T�IEREON,AND
� WYOCONTRAGTSFORSUCHPPOJECT3WITHACONTRACTOqf'�I�CEM1SEDPURSVANTTOTHFGONTRAC- Q()ANTITY DESCRIPTION FEE
TORS LICENSE UW.j. -
Y J
� iJ 1 AM EXEMVT UNDER SFC. B.8 9C.fOF TNIS HEASON Q
p --.....— V .
� — �
� OATE C�WNER_ _. _,__ ~
Z W
� LICENSED CONTRACTORS DECLARATION }
� LtJ
Q
CL I4EREBV AFfIRM UNDEft PENALTf OF PERJUR"'HAT 10.M LIGENSED JNOtH PNOV�SIONS OF CHAPTER �
d 9(COMMENCING WITM SECTION]ooUi OF D�y15lON 3 OF 1HE 9USINESS AND PRO�tSSi.7N5 CODE,ANC� z
`X MY UGENSE IS IN FULL OHG A'D EFFECT. m�
� LICENSE CLASS _����C NO_-����� ��. • J I
�I�(A/n
r– ('1 �`f-�15�
U DATE_�IC .,_����_ CONTPAGTOF n-
W
� WORKERS'COMPENSATION DECLARA710N Q
� U
� I MEFEBY A�FIRM UNDER PENALTY OF PERJUqY ONE OF THE FOLLOWMG DECtARATIONS: Z
� I VE ANO WILL MAINT4IN A CERTIFICATE OF CONSENT TO SELF-�NSURE FOR WORKERS' _
Q �MPENSATION.AS GROVIDED BY SECTION 3]Co nF THE UBOR CODE,FOR THE PERFORMANCE `U
OF THE WORK fOR WHICM THIS PERMIT IS ISSUtO. cL
0 n
W I NAVE AND WILL MAINTAIN WORKERS'COMPENSATION.NSUAANCE,AS REOUIRF.�BV SECTION � i\
Q 3�m O�THE LqBOF COOE.FOR THE PERFORMANCE OF THE WORK F�R WhICH THIS PERMI?IS U
ISSUE�-M1'WOfiKE "' OMPENSATIOI: U�ANCE G RRIER AND POLIGY NUMBERARE'. CONSTRUGTION
j c�nwea__ N� PLAN REVIEW . _
� �oucrr+urnneR__.�,__ — ✓ --- FLECTRIC
Z
¢ (iNISSECTI(YJNGmNOTBEO�AAPLETEDCFiHEPERMf�iS�HONEHUPOPEDOCllAPS(5100)OqLESSJ. PLUMBING _. ._
�
w MECHANICAL __
Z I GERTIF�THAT IN TFIC PERFORMANG_DF THE WORK FOR WHICM TI�IS PERMIT IS ISSl1ED,I -- -�
(,r} SIfALL NOT EMPLOV ANY PER50N IN ANY MANNER 50F5 TO OEGOME 5t19JE<:T 101Ht
� WORKERS'COMPENSATION lAWS 0F GAIIFOR�IP,ANU PGHEE`HAi IF I SHOI;'�O BECOME INS:�EGTION FEE __ . —
SU&lEC7 TJ THE WORKtHS'COMPENSAIION PAOVISIONS OF SECTION 3700 OF THE LABOR
� GO�E.ISHALIFORTMWiTHCOMPLYWI'MTHOSEPROVISiONS. ISSUANCE _ /'�
O SMIP _ '•� " _
p naTe aaPucnNr. _ —
w ENERGY P/C __ .—_—_
—� WARfvING.fAILUFE TO SECURE WORKERS'GOMPENSATION GUYERAGE IS UNLAWFUL,AND SHAIL BE
J
� SUBJEGT AN EMPLOVEF TO CiiIMINAL PENALTIES ANO CIVIL FINES UP TOONE HUNDFED THOUSAND ENERGY PERMIT _ _._
�ollAF5lftoo.DOD?.1N A��'�TION TO TN'_COST 0i CGM�ENSATION.DAMAGES AS PAGVIDED FOR IN I�
J SECTION 3]080f T4E LABOR CODE.MTEFEST,ANDATTORNEV'S FEES. RETENTION FEE: _ _. l��
�
W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� -
O
� IMEREBYAFF'�RMUNDERPENALTVOFPERJURY`HATTMtHtISACONSTFUC'.IONLENDINGAGENf.Y _
� FOR THE PEFFORMANGE OF TME WUFK W N WMIGH iM15 PEFMIT IS ISSUED(SEC.3091,CIY.C.�.
Z -
w
2 �ErvoEN•s NnME_, _.__ —_�— -- _ __
� — —
F- LENDEA'SA�DRESS .._— —�— - ':
� 1 CER'IFY TH>T�:�AYE ftERD�ri15 APP��CP?t 54D STATE TMAT TNE ABOVE IMFUHMAIION IS COflRECT. TOTAL FEES
w 1 AGREE TD COMPLV WITM ALI.CITY UNTV URDINANGtS ANO STATE lAWS HE'_Al I4G TO AUILDING
� GONSTRUCTI EREBY IOFIZE REPRESENTATNES OFTHIS CGUNTVTO ENTER UPON TIiE
� ABOVE- � ONEO PR P FOR INSP CTIO
Z �-Y�����, ^�` r COMMENTS _
� �►�[�i
� -- _ b�—i�r_
m PEFMITTEE IE(P T)
¢ � " ��
�
— —_ .'_'.. _— '__— - _ _'..___- _" —__'--_
� SIGNAiIiqF F�EF ITTEE �4
� RECPT..�O. PAID BV VALIDATION
_
~ HITE--Department Gop}',YELI OW—Finance Copy,PINK—Asseswr Copy,GOLDENROD—File Gepy,GREEN—Applicanfs Copy
. � � � . . , ,, �i ..
.. ��., ��,.. ,����� ,.� F� � e ,�� �� a;�
'� � a� ° �� �,�. �y . .
s , � �
���� � �� ��,x'��`*,� �
���._ , � _�
_ _
�� �¢.� ��n __ _ _
, ;� �
__ _ _ _ __ __
. _. __.._ _ __ ;
_ __ k
_ _. ;
_. _.. ;
_ _ ;
����,���� �� �,� �P � ���x . �
�r� � � 1 � e�, � . _ _
�,�.,., __
., :,.
�,
r
�` _
�=>s�s,,, �
� ;. �
�. r " tl �I}�� � '
��<. � � _
�: +;
M
�" _
,
w;���' �� �G �
r ,
� .'+ ._. . . . . .. .. . . . . .. . .. ._.... ...... . . _. . ..... .. ..... ��.
b��.
�� �
,���� _ _ �
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
11
ADDRESS__0 V W65
APN LOT T ACT
OWNER V%A Z.9ysJ Q �I4
ADDRESS
CITY ZIP TE
APPLICANT TEL.
CONTRACTOR
ADDRESS-W?
CITY ZIP TEL
C�
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 REOUIRESA PERMITTO 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 SUI3JEC IS [HE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(11500))
^ 1.AS OWN ER 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 WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OH
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,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 TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORIS)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
LJ I AM EXEMPT UNDER SEC. B&P.0 FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM LINDER 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 FUL
L ORC A D EFFECT
.�
LICENSE C
LIC N0. �•7 j
DATE/}
yo/_L CONTRACTOR y,W
WORKERS'C
OMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I VE 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
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 WORKS
ER AND POLICY NUMBER ARE
CARRIER
T;Mm
POLICY NUMBER/�_
(THIS SECTK)N NEED NOT BE COMPLET ED 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 COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(S10o,0001. 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 APPLICATI AND STATE THAT THE ABOVE INFORMATION IS CORRECT
1 AGREE TO COMPLY WITH ALL CITY UNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCT,EREBY ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-ON ED PR P FOR INSP CTIO S.
PERMITTEE E(PR Or?
SIGNATURE F PEE ITTEE
0
Cr
0
I)
W
z
0
12
0
Q
0
In
W
U
W
0
C-)
0
a)
Z
Q
2
d
X
W
0
F-
U
W
C/)
C)
W
J
C)
0
W
C3
U3
0
I)
LL1
LL
W
cl-
0
OC
0
Z
W
S
F-
LU
Z
0
on
Q
CI)
co
I-
APPLICATION OR PERMIT i
DATE 0 dR• 1'Z NUMBER,
S0. Ff.
ISSUE r]j b TYPE OCC
DATECONST GROUP
ZONING
SETBACKS
FRONT
REAR
SIDE/SIDE STREET RW
SIDE
N0. DWEL. 7 N0. N0.
UNITS STORIES BEDROOMS_
7- 1
w
DESCRIPTION
SFR/ADD/REM
Garage/Carport
Patio/Deck
LL
(.7
z
0
Pool/Spa
Re-Root
Commercial
J
U
I-
U
(Si
LLI
FACTOR PSF
Valuation_ 1,2 UL1V ADJ.AREA
QUANTITY
0
ED
n
Q
0
Z
2
0
LU
2
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTlON FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0._PAID BY �'L,j,�I VALIDATION
HITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy. GREEN-Applicant's Copy
DESCRIPTION
P/C
ADJ.AREANALUATION
FEE
PRESS
FIRMLY
RW
rTT