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Home My WebLink About14890 (19)C u L L CITY OF DIAMOND BAR" DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 PRESS FIRMLY BUILDING PERMIT APPLICATION 1013SITE ZDRESS--g!�w'r 'P N T TRACT 77411—O&P I OWNER t I ADDRESS __q / 17144 filelf CITY I E APPLI ADDRESS I'' " 41 TEL CONTRACTOR-... DDRSS . I A EE OF, CITY h _W214 TE , ARCH/EN ip DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I 'AM EXEMPT FROM 1`119't6NT�AAq LI- CENSE LAW FORTHE LOWING REASON (SrC.71531.58USINIESSAND PROFFSSi6LIlf,411§'dobr'4Ar4Ydi"YOFI FOLLOWING 0OUNTYWHICH REQUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOS11.0REPAIR ANY STRJC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A MGNE13 STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS Or THE OdWhAd`�OFIS Ll - CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION a OFTHE 1508INESS'Aft PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED III TION. ANY VIOLATION OF SECTION 7031.6 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACrALPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ISSOOM' (3 1. AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WORK " B US111 WILL DO THE AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR'SALr J§IIEG] 7044','13USI. NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, WHO Core SUCH WOnKHOI OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH' IMPROVENENTbVtENCT INTENDED OR OFFERED FORSALE IF, HOWEVEFLTHE 13ULDING CRIMPROVEMENT IS SOLD WITHIN ONE YEAR O'AMPLE OWNER-BUILDERTION,THE WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT D OR Pp"i4d" IMPROVE FORTHE PURPOSE OF SI 11;44 111 S , E , �4 0 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH L; WRACTORS To CONSTRUCT THE PROJECT (SEC. 70", BUSINESS AND PROFESSIONS 00M THE CbNTRAG76AS LI- CENSE LAW DOES NOT APPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR N04 ROVES AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONITsAaron'(s) ucENSED PuFISUA14T, Tb'THII. CONTRAC- TORS LICENSE LAW.). 0 1 AM EXEMPT UNDER SEC. R. IF P.C. FOR THIS REASON f j , DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROPEISSIONS CODE-, AND My LICENSE IS IN FULLF04M AND T EFFEC LICENSE CLASS LIC. NO DATE CONTE WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: —I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' comprNSAFION.As PROVIDED BYSFCTICN 37w oMr LABOR CODE, POATHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. --I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS' REQUIRED BY SECTION 3700 OF THE LABOR 0009. FOR 'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY T�ON �I :ICY NUMBER ARE WORKERS' N 1 W;�NCE;Zq�� –BIER ANO POI:ICY C 7 CARRIER A 1-+ POLICY NUMBER W1 4111097--_ (THISSECTION NEED NC)TSrCGMpFErEOOFTHE PERMIT IS FORONEHUNDRED calAss($1d6y dRLESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED; I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS To BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREF THAT IF I 8�10ULCI BECOME SUBJECT70TH E WORKERS' COMPENSATION PROVISIONS OF SECTION 27000E THE LA; 666 I SHALLFORTHWITH COMPLY WITH THOSE PROVISIONS, DATE: 4111PLICANT WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,II00). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED EOFI IN SECTION 370007 THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. j CONSTRUCTION LENDING AGENCY 5 I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED JSEC. 3697, CIV C.). Ll LVNDERSNAMr -- LENDERS ADDRESS rU ICERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. L AGREETo COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES or THIS couNTY"ro ENTER UPON THE ABOVE-MENTIONED PROP TY ED INSPECTION PURPOSES. R IN EJITTEE NAME (PRINT) 123 So APPLI I C4TIO co PERMIT P/C DATE NUMBER # ISSUE TYPE OCC DATE: CONST. GROUP ZONING SETBACKS FRONT RW 0 REAR 11 SIDE/SIDE STREET RW 11 SIDE 0— PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT FACTOR PSF ADJ. AREA/VALUATION 5FRIADDIREM Garage/Carport U) LU Patio/Dock Pool/Spa Re -Roof CI Commercial 5 ca Valuation ADJ.AREA A OUANTITY D SCRIPTIPN FEE ni dl cc 0 LU w -I C9 Z 0. Z CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING FATT) MECHANICAL INSPECTION FEE n -n non Ar K 1— u ISSUANCE 31 I -M l 11 �MI SMIP Crfi &N s"I M�Ty ENERGY PIC 7 ,8 ._Un, ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS CPT NO N VALIDATION' HITE—Department Copy, YELLOW—Filing Copy, —py.