HomeMy WebLinkAbout11684CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
W 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
>. �°"BUILDING 1'ERMXT,APPLICr�.�'ION.
JOBSITE f
ADDRESS (_eo26 157-R -2
APNLOT TRACT
OWNER ��3 f �SCe4nl
ADDRESS S _
CITY 7 w, ZIP TEL. Vpi
APPLICANT TEL.
CONTRACTORt1ST/?(t 074AJ
ADDRESS ,3 C'f (A -e &ev4V
CITY W- Coat,Ai�. (� ZIP !?/2'P -?.TE �(
ARCH/ENG/
DESIGNER -�
ADDRESS
CITY ZIP TE
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY. THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC. 70314 9USINESSAND PROFESSIONS COPE: ANY CITY OR
COUNTY WMCH RECUIRESAPERMITTO CONSTRUCT. ALTER. IMPROVE. DEMOLISH. OR REPAIRANYSTRUC-
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 LIS
CENSE LAW (CHAPTER a (COMMENCI,NG WITH SECTION 7000) OF.DIVMIQN 3 OFTHE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANYVIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CAVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
❑ I. AS OWN EROF 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, 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 CR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED POR SALE IF HOWEVERTHE BUILDING ORIMPROVEMENT IS SOLD WITHIN ONE YEAROFOOMPLE-
TKRI, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE),
❑ L ASOWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U -
CENSE LAW DOES NOT APPLYTO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT. / /([,['' �]
LICENSE CLASS /yam_ LIC. NO. (Q INS- "7
DATE .�" CONTRACTOR 'X&'et
WORKERS' COMPENSATION DECLARATIONS
I HEREEYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATION1~✓1 V
_ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE 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 HAVEAND 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 CARRIER AND POLICY NUMBER ARE:
POLICY NUMBER / Z
(THIS SECTION NEIDNOTBE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOIARS ($100) 08 LESS)
I CERTIFY THAT 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 SUBJECT TO THE
WORKERS' OOMPENSATK)N LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECTTO THE YORKERS' COMPENSATION PROVISIONSOF SECTION 3700ELABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE OVISIONS.S.
DATE: _ �.3d 5 APPLICANT {—
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, D SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($1W'000), IN ADDITION 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 IS ISSUED (SEC. 3007, CIV. C.).
I
LENDER'S NAME
LENDER'S ADDRESS —
1 I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT.
(AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
N,
CONSTRUCTIOAND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTbNEO PROPERTY FOR INSPECTION PURPOSE
's
) PERM( E NAME (PRI )
) BNA E F ERM TTEE DATE
PRESS
FIRMLY''
APPLICATION y ^fir C
DATE77 l NUMBER #f !
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE Cl
ROPOSED USE.00t d t lL 1<t k k7,- Ad �
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. ARE AILLATION
SFRIADD/REM ( z
Cn
Garage/Carport
WPatio/Deck
-
LL
PooUSpa
Z
Re -Roof
Commercial
L "
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
¢
d *" -Put .S -t- Sw, fc ti r s i Id
nrfde_ SCALItcratw 7 b
l t t
res Loo
W
Z
/ +
> /_
0
O_
l StiC Gi �" S Rl••. c /Tr
v
eLoC C. $ 8we V -e --t s(�
X-C to crtk A, Ute`' �Li
a
v
Z
LU
CONSTRUCTION
PLAN REVIEW
ELECTRIC 03
PLUMBING I
MECHANICAL i (�
INSPECTION FEE
ISSUANCE -�
SMIP
ENERGY PIC 33,6 1
ENERGY PERMIT -
RETENTION FEE: r
PRE -ALT FEE:
ii
TOTALc'
OT
9FEES
COMME S ' Y `VV6�Y1
�
RECPT. N0. PAID BY YALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GULUhNHUU—rue L Opy, uHrMIV—Mppm;xln s wpy