HomeMy WebLinkAbout8863CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
�. 21660 E. Copley Drive Suite 190 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE
ADDRESS
APN LT RACT
OWNER r
ADDRESS a
CITY 11 ZIP TEL.
APPLICANT __ TEL."
CONTRACTOR c
ADDRESS
CITYZIP USL' TEL
ARCFVENG/
DESIGNER
ADDRESS
CITY r ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSK)NS CODE; ANY CITY OR
COUNTY WHICH REQUIRESA PERMRTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC.
TURF, 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 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 AND THE BASIS FOR THE ALLEGED 5)(EMP.
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSOO).):
❑ I, ASOWN ER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. TDM. 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 FOR SALE, IF, HOWEVER, THE BUILD Nr IMPROVEMENT IS SOLD WITHIN'ONEYEAR OF'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)
O I, AS OWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TORN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES
THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(SI LICENSED PURSUAN7T0 THE CONTRAC.
TORS LICENSE LAW.).
O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONSOF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT,
LICENSE CLASS LIC. NO. "
DATE CONTRACTOR �. 1;,
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 SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDFO 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 or THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED CARRIER Y WPRKERS QOM INS URAN CARf71E D POLI CY NUMBERAREi -
POLICY NUMBER 2 j
(THIS SECTION NEEDNOTSE ODNPLETEDOFTFE PERMTIS FOR ONE HUNDREDDMLAAS 0100)ORLESS)
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO CA ME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND EE HAT I I SHOULD BECOME
SUBJECT TO T E WORKERS COMPENSATION PROM S OF CTI 3700 OF THE LABOR
CODE.. SHALL yCRTHWITH COMPLY WITH THO P BION f�f`
DATE: ` APPLICANT: '-
WARNING: FAILURE, OSE URE WORKERS' COMPEN TION COVERAGE 15 UFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES DCIVIL FINES UP TO H DREDTHOUSMAO
DOLLARS ($100,000), IN AODITIONTO THE COST OF COMPENSATION. DAM ES. S PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, /
CONSTRUCTION LENDING AGE GY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDER'S NAME
LENDER'SADDRESS
I CERTIFYTHAT I HAVE READ THIS APPLIGATIONAND 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 PURPOSES.
%, CA `
PERMITTEE NAME (PRINT)
P "4
SIGNATURE OF PERMITTEE DATE
APPLICATION ' . PERMIT(/ P/C
X
DATE NUMBER'__ #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
81DEISIDE STREET RW O
SIDE ❑
PROPOSED USE 1/t
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
WPatio/Deck
LL
Pool/Spa
ZRe
-Root
Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC _
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMTP I/
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
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TOTAL FEES
COMMENTS
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RECPT, NO. BY VALIDATIONLi
WHITE—DaWrtment Copy, YELLOW—Finanoe Copy, PINK—Assessor Copy, GOLDENROD—File COPY, GREEN—Applicant's Copy - , 11. -"1 i
CITY QF,.PIAMC?NP,,BAR
�3 fINSPECTION REPP13P
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SEPTIC TANK SIZE
S,5515-PIT/U SIZE'
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