The URL can be used to link to this page

Home My WebLink About11684 (5)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES W 21660 E. Copley Drive Suite 190 (909) 86073195 Fax (909) 861-3117 BUII,DIi�1G 1'ERMXTIAPPLICATION. _ JOBSITE f ADDRESS (_eo2t6 APNLOT TRACT OWNER d�3 i�1J �.1SCe4nl ADDRESS S _ CITY 7 w, ZIP TEL. Vpi APPLICANT TEL. CONTRACTOR ADDRESS A . C-AL(('e &evA-� CITY W- Ccaat,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 REWRESAPERMITTO 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 9 (COMMENCI,NG.WITH SECTION 7000) OF.DIV,ISK)N 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- TION, 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. E. & 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 /y)__ LIC. NO. (Q ( LL_,L' DATE l .�' CONTRACTOR �yLG �.. WORKERS' COMPENSATION DECLARATIONL-�i I HEREEYAFFIRM UNDER PENALTYOF PERJURY ONEOFTHE FOLLOWING DECLARATIONS 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 HAVE AND 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 NEIDNOTRE ODMPL.ETEDOFTHE PERMIT IS FOR CNE HUNDRED DOIARS (5100) OR LESS) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON INANY MANNER SOAS TO BECOME SUBJECT TO THE WORKERS' OOMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECTTO THE WORKERS'COMPENSATION PROVISIONSOF SECTION 3700�LAOOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE OVISIONS. DATE: y,3'7/ IIS 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. 3097, CIV. C.). LENDER'S NAME LENDER'S ADDRESS — I CERTIFY THAT I HAVE READ THIS APPLICATON 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 PURPOSE L PE -RMI E NAME (PRI ) -&GNAT(ME5FTirRMfTTEE 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.0 0t d t lL 1'C t FC k -v, - 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 Valuation ADJ.AREA QUANTITY DESCRIPTION FEE ¢ d *" -Put .S -t- Swr fc ti r s i Id [t nrtdP SceviCrg&' 7 b l W J W C'T Z / > /_ 0 O_ l StiC Gi �" S Rl••. c /Tr v ,-_Loc C. $ 8we V -e --t s!� a X-C tCc rA-k t, llr,- � L i v Z O W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING r MECHANICAL i (� INSPECTION FEE ISSUANCE -� SMIP ENERGY PIC ENERGY PERMIT - RETENTION FEE: r PRE -ALT FEE: ii 19 CA T�yO�T c 1' 9/F�EES /rte y`{ J ,�[ 'y"�1 COMMENTS V Y `" - ' &V IS �YR RECPT. N0. PAID BY - .YALIDATIOI WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor copy. UULULN"UL—rue 4opy, a vupy