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Home My WebLink About16252 (23)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES w 21660 E. Copley Drive Suite 190 (909) 860_,3195 Fax (909) 861-3117 . BUILDING PER Iff APPLICATION JOBSITE ADDRESS %r APN LOT TRACT OWNER ADDRESS CI k2 ZIP TEL. P APPLICANT TEL. CONTRACTAketmnk 14 ADDRE�S CITY ZIP TELA/' ARCWENG/ ` DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LT CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY 017YOPI COUNTY WHICH REQUIRESA PERIWTTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC- TUBE, PRIOR 70 ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TOFILE '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 ANC�PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR 7HE ALLEGED EXEMP. TION. ANY VIOLATION OF SECTION 7031.6 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ❑ 1, 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 OFFEREDFORSALE (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 FORSALE, IF HOWEVER THE BUILDINGOR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE. TION, THE OWNER43UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT�3UIUD OR IMPROVE FORTHE PURPOSE OF SALE). ❑ I. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHAOONTRACTOR(S) LICENSED PURSUANT TO THE OONTRAC? TORS LICENSE LAW.). O IAM EXEMPT UNDER SEC. B. 4 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 AND EFFECT. UCENSE��C�y�yLA//y�y�,,��LL LIC. NO. �- T DA17, g= J CONTRACTO '""�� WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: -I HAVE AND `MLL MAINTAIN A CERTIFICATE OF CONSENT TO SELr4NSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR'WHICH THIS PERMIT IS ISSUED. _I HAVE AND Iffl-L MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 5700 OF -THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKER ' MPENSATION INSURANQQQE CARRIER AND POLICY NUMBER ARE: CARRIER , POLICY NUMBER r6V MUS SECTION NEED NOT BE COMPLET=_DOFTHE PERMIT IS FOR ONEHINDREDDOLIARS ($10D) OR LESS). I CERTIFYTHAT 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 SUBJECTTO 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 ALL F THWITH COMPLY WITH THOSE P VI 5. DATE: �PPLICANT: WARNING: URE O SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SU13JECTAN EMPL YERTO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS (f100,000j, IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFPAM UNDER PENALTY OF PERJURY THAT THERE IS AOONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3097, CIV. C,). LENDER'S NAME LENDER'SADDRESS 1 CERTIFYTHAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CRY 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 N PRI T) SIGNATOR PERMI EE DATE PRESS FIRMLY APPLICATION PERMIT i �' P/C 41 DATE NUMBER \ # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ P O �E US A tT 1 NO, DWEL. NO. NO. UNITS STORIES`` BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD(REM Garage/Carport U-1 Patio/Dock U- Pool/Spa :3 Z Re -Roof dCommercial - m Valuation _ _ ADJ.AREA QUANTITY DESCRIPTION FEE Q U .. F_ U w w z Z EZ 0. d U 2 2 LU CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL _ INSPECTION FEE _ ISSUANCE --•--_._._ _ _ n _ ENERGY P/C ]q_p�D ENERGY PERMIT R R RETENTION FEE: PRE -ALT FEE: TOTAL FEES , COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Cody, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy. GREEN—Applicant's Copy {'_ K OCR p, 3. P NG------------- mok- Hr BONO AM {'_ K OCR p, 3. mok- Hr BONO AM � J POS E 9 i POOL F,INA� RENAL }e... .. ------------- r - I `^ Y p m wr-