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Home My WebLink About17386 (25)CITY OF DIAMOND BAR (—F)^�-``--DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive m (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY ODDR TE ADDRESS ESS /a.;�O �, Gran 2 14V4 APN LOT TRACT OWNER ADDRESS CITY ZIP TEL. APPLICANT .%j TEL7�±Y 609.Y& L41 CONTRACTOR ��M ` e NL ADDRESS -6-1.D c1T 7AA Ell r- ZIPVil D TEI ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL, OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U - CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITYOR 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 U- CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION OFTHE BUSINESS AND PRO- FESSIONS CODE) ORTHATHE OR SHE IS EXEMPT THEREFROM ANDTHEBASIS FOR THEALLEGEDEXEMP- TION. ANY VIOLATION OFSECTION 7031,5 BY ANY APPLICANT FORA PERMIT SUBJECT5 THE APPLICANTTO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6500).): 01, AS JI,AS OWNER OFTHE 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 WOP,KHIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OROFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR 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). ❑ 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS 'TO CONSTRUCT THE PROJECT (SEC. 70", BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI - ,CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG- TORS LICENSE LAW.). ❑ I AM EXEMPT UNDER SEC. B. 8 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 4 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFEECT. /J LICENSE CLASS �yWPAIZG//� 7S L C O. DATE,E3 CONTRACTOR 7E -ired IAUG WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: ,y/ — HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BYSECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 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 WORKERS' COMPENSATION INSURANCE /CA PIER AND POLICY NUMBER ARE: CARRIER,JI��`1 POLICY NUMBER !V 7 H (THIS SECTION NEED NOT BECOMPLETEDOFTHE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) ORLESS). I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATIONPROO VISIONS OF SECTION 37000F THE LABOR CODE, 1 SHALL FORTHWITH COMPLY WITHTH 'E ROVISIONS. DATE: �� D I APPLICANT: —, WARNING: FAILURETOSECUREWORKERTC ENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($I W,D00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370E OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBYAFFIRM 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 I 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 ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE NAM T. SIGNATU PERMITTEE DATE D/ CATION I 0 t ,6 ®4 & � DATE NUMBEd_7 #/C ! r ISSUE �' TYPE OCC DATE CONST GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ, FT. FACTOR PSF ADJ. AREAIVALUATION' SFR/ADD/REM fn Garage/Carport Patio/Deck LWL.I U- Pool/Spa 0 Z Re -Roof 0 Commercial - CID Valuation - ADJ.AREA QUANTITY DESCRIPTION FEE J U F U W W 0 Z m a U_ Z 2 U W CONSTRUCTION t v� \� PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMTP 19 L2 ENERGY P/C ENERGY PERMIT RETENTION FEE: f PRE -ALT FEE: TOTAL FEES 50 —+ � (P .5 0 COMMENTS QIICW r r ar_ j ®6 _ (00 r _ RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy E', E;: " F- 33 ' ZE --- — ------ AIAJA-ml HR'm A; N 31; m. 1 — -- ---------- Gl—",U c n", fk p i'A I Z D C� R-�,C, F S IH" ID d .per hl ------ -- --- ivr -slr D Rll"IJIVAL�- 'Al. 1� 0 Cl -------- ----- . ..... . . .. ... . .. . ....... 11 1 1 kv- M Pie, I E', E;: " F- 33 ' ZE --- — ------