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Home My WebLink About12784CITY OF DIAMOND HAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES w 21660 E. Copley Drive Suite 190 (909 ) 860-3195 Fax (909) 861-3117 2� 2� JOBSITE ADDRESS rr Si DJ2. APN LOT �!-_ TRACT` rI OWNER Q1,(MoA/1) �� f1P X9(00111(22 TEL APPLICANT VJ Q j TEL. ADDRESS T- RD, -R - ZIP 0 (�� TEL CONTRACTOR L1D <T PA(j:QrA (Z�. ADDRESS 20 it Q$PgT tZ f) ,-43 10 Z �/�y-� CITY ARCAb A ZIP--i�?O'J TEL(�)SN?J.4_Y.VI.J ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS 1 -1 - Cr NSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANYCITY OR CDUNTYWHICH REQUIRESA PERMrrTO CDNSTRUCT,ALTER', IMPROVE, DEMOLISH, OR REPAIRANY STRUC- TURE. PRIOR TD 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 1.1- CENSE FCENSE LAW (CHAPTER a (COMMENCING WTH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THATHE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION, ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($6Do).): ❑ I,AS OWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WALL 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 THATSUCH IMPROVEMENTS ARE"NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAROP'COMPLE. TION, THE OWNER.BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE On 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 COOS: THE'CONTRACTORS U - CENSE UW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THEOONI TORS UCENSE LAW). ❑ IAM EXEMPT UNDER SEC. B. 8 PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT, 5-f ,( �7Q LICENSE CLASS b 5 LIG. NO. Cif L/ ,3 DATE [ -x -(O !�8 CONTRACTOR at!) 3414 41 C WORKERS' COMPENSATION DECLARATIONS 0 --'- O O 1 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' COMPENSATION, AS PROVIDED BY SECTION 37000F THE LABOR CODE, FOP THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERTOOMPENSATION INSURANCE, AS RECUIRED BYSECTION 370o OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CARRIER POLICY NUMBER (DISSECTION' NEED NOT BE COMPLETEDOFTHE PERMIT IS FORONE HUNDRED DOLLARS ($10D) ORLEW, I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SD AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSEROVISION$. DATE: 12--t0!:91k 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 (S1OD.DDO). IN ADDMON 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 I$ ISSUED (SEC. 3097, CIV. O.). 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. IR A/ �Q PERMITTEE NAME (PRINT -.G1 et d.T�— I . Q '` d I SIGNATURE OF PERMnT DATE I PRESS FIRMLY APPLICATION �C PERMIT /C DATE NUMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SrPJADD1REM W Garage/Carport W Patio/Dock U- PCCISpa ZRe -Roof O Commercial - In Valuation - ADJ.AREA QUANTITY DESCRIPTION FEE d C) U W W C7 -- z ~L Q U Z d z U W YG' CONSTRUCTION LEC a PLUMBING MECHANICAL INSPECTION FEE ISSUANCE L SMIP — ENERGY P/C t . ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: _ TOTAL FEES COMMENTS ( RECPT NO. PAID BY 'VALIDA�fION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy CITY OF DIAMOND BAR lNSPt(,-Tl0l%' RECORD U 10 of NION a_ BACK SET .;... lr o '" - C. G9 " Ls i ¥ i, -----4-'-UND i" )�l:—i ..+ i SLAB GRADE s� _ _....:_ "aREP;.A � j:` tAl!0—I' I ►'a 11'.= "k —'� "EM -P POWER Fl L JT FINAL BONED AM ROUGH HEATING BENCYING r=te .a`t ac-g PLIJMiNFINISHIGRADING o „ s �`s i POOLELECTRIC E ( i r,ri —gig 1p _—...--_-._.<_.-..w_ ... .._...._ . —_—.—.._— ._ V�X.LLWISIULA-71 POOL FINAL DEDICATIONS E L;-4Na ,Al"`XaRR'i~.. ECP GAS AIR TEST mi -NAL HE rr. F'iwL FINAL ELFCTR�G DEV. 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