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Home My WebLink About13350 (17)CITY OF DIAMOND BAR _ DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 864-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITEADDRESS f L� YJ /Cy %j G of j -r ADDRESS tai i 1 j APN LOT TRACT OWNER S ` �� . ADDRESS r CITY ZI it /J4 . TEL. APPLICANT TEL. 26 -VII -04 CONTRACTOR ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- RTHEFR(SEC. ?W1.5 BUSiNESSAND PROFESSIONS CODE: ANY CITY OR COUNTYWHIOESAPERMITTOO CO CENSE LAW THE OLLOVANO REA NSTRLIC7,ALTER, IMPROVE, DEMOU5H;ORREPAIRANVSTRUC- 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 OFTHE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CMLPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (IISOOM: O 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, 8USI- 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 IMPROVEMENTSARE NOT INTENDED OR OFFERED FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE. TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 0 I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICU48ED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTSFOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONI TORS LICENSE LAW). ❑ 1 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 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AN FECT.�/g/ JJC�p LICENSE CLASS �R, LIC. N. _6 toQ ld. qll DATE =j _V° CONTRACTOR -r 1,�SZ_ 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' COMPENSATION, AS PROVIDED BY SECTION 37M 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 11 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMSAT INSURANCE,CARQRI'ER PND POLICY NUMBER ARE: CARRIER iGr��/p'!" Vp '.*n� POLICYNUMBER 7 '::Z?^ ( 1 (THISSWRON NEED NOTBE COMR-EFEDOFTHE PERMT S PTP, ONE HUNDREDMIARS (SIOD)OR LESS). I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE[), I SHALLNOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPVSAND OVISIONS OF SECTION 3700 OF THE LABOR COD .I ALL 7THWITH COMPLPROVISIONS. DATE: ^� 1 APPLICAN WARNIN : FAILU TO SECURE WORKERS',ON COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENAIL FINES UP TOONE HUNDRED THOUSAND DOLLARS (s100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 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 IS ISSUED (SEC. 3097, CIV. C.). LENDER'S NAME LENDER'SADDRESS 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 70 ENTER UPON THE A80VE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEff�l INT) ' SIGNATURRR-Eb MrrTEE! DATIF IF PRESS FIRMLY _ Ic� APPLICATION -qq/C DATE NUMBER _ _ 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 SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR(ADD/REM Cl) Garage/Carport WPatio/Deck U- Pool/Spa 0 Z Re -Roof Commercial m Valuation ._..` ADJ-AREA QUANTITY DESCRIPTION FEE ULu Lu160 ' g CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING ECHANICA ` ON FEE.'" ISSUANCE SMIP ENERGY PIC c ENERGY PERMIT RETENTION FEE: ' . (� ✓ PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW--Finanoe Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy CIT"A" C)F DIAINIONDa BAR C"'fl '"CiMRD INSPETiCN FIE