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Home My WebLink About7955CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT .:¢ 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 561-3117 BUILDING PERMIT APPLICATION JOBSITE % ADDRESS 12 APIN LOT , TRACT - — OWNER /iLXz-.1/ilS�i1✓�/ ADDRESS CasGY %I�C7L/! �Si" CITY ' eraA% ZIP TEL.a%', %✓�i� APPLICANT AE;25 CONTRACT R d ADORES CITY % ZIP 99,9 TEL y' OS923i/ ARCH/ENG/ DESIGNER,IO►2f ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANYCITYOR COUNTY WHICH REQUIRESAPERMITTO CONSTRUCT,ALTE, IMPROVE, DEMOLISH, OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAYHE 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 AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM ANC THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ❑ I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLECOMPENSAT Dr,( WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, SUSI. NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVIESTHEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENTIS SOLD WITHIN ONE YEAROF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE 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 LH CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ❑ I AM EXEMPT UNDER SEC. B.'$ P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURYTHAT I AM LICENSED UNDER PROVISIONS OF CHAPTER e (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS INFULL FORCE AND EFFECT LICENSE CLASS ,4'- �' d. ! LIC. DATE �l "! �"7� CONTRACTOR �VdA�I. �(�'br� 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 SELFINSURF FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE /SOF 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 WORKFOR WHICH THIS PERMIT IS ISSUED.MYWORK+�R,Sj',CyO�MP�ENS/A^TION USUE"CE CARRI R AND POLICY NUMBER ARE: CARRIER C:►�JA..'�f-7"6�L. ){�� POLICY NUMBER ? — 9� zzot fir (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS} I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALLNOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT !F I SHOULD BPOO ME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR COODD`E, I SHALL FORTHWITH COMPLY WITH TI - DATE: DATE: ,fi -J �J� APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS (5700,00)); IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOP, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY IH REBY 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.). LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CORRECT. i AGREE TO COMPLY NTH ALLCITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE 7;3ON PROPERTY FOR INSPECTION.--. P� URP�S�S. �� PE MITTEE NAM) S N TURF O PERMITTEE DATE PRESS FIRMLY APPLICATION PERMIT P/C DATE '� ,b / NUMBER # ISSUE TYPE OCC DATE CONST, GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE -il NO. DWEL, NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM � Garage/Carport W Patio/Deck LL PooVSpa ZRe -Roof / Commercial m _11if V -I .TI or W. ADJ.AREA QUANTITY DESCRIPTION FEE J Q U U w W U Z E51 a Q _U Z Q W CONSTRUCTION - PLAN REVIEW ELECTRIC J PLUMBINGMECHANICAL INSPECTION INSPECTION FEE _ ) s�-_l�sry��, �'`✓t%/ ;, ISSUANCE SMIP ENERGY PIC e _ ENERGY PERMIT"' - RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT NO ` A?D BY ALIDATION W IT —Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy Rl HT. BC)ND BEAM R.x*„Ayy �'*"r-'a&mE4[--- ... �' `��r;. c.. g. 1=71-1did 9 Br ---AM ` R --A l,A R --t ¥ 1` toN - J. r ._.._.. m_a t BO N IIA � ..._ ROOF e'OVr-PlPRE-GRAZING F iar it SEN 'HIND j ROUGHGRADING BINC _ �nOO' ELECTRIC EXT L '� 3s PC s FENCING T # _ 9 C�.1L a w„ ? � � iOFF SITE ii�,. L LING RNIL ENG. !�y g�� . ..._._ SEPT �C TANK ON SITE WS 4EEF 7[L _ci k ST FiNAUZSJ191Ni.'. C;