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Home My WebLink About17646 ��,` CITY OF DIAMOND BAR ! t�,.� � � � DEPARTMENT OF COMMUl+�IT'Y&,DEVELOPMENT SERViCES 1.....i 2t825 E.Copley Ih'rve PRESS ""� {904)&60-3195 E�(909)861-3117 `�%�M»'` BUILDIIVG PERMIT APPLICATION FIRMLY � JQBSITE ��- ^��" `� , l��' �,..y APPLICATIO� � ��.,�.., NUMBER� (,r �' #/C o AdDRESS � t-� dATE o ISSUE TYPE OCC `� APN_._�___ LOT TRACT,"^_ DA7E CONSL GROUP Q C7WNEFt __!�l��yLC`� � 7 y- ADDRE 3__�� /�..._�.�rL.�� ZOMNG SETBACKS o ..- FRONT RW _� ❑ � GIIY � � ZIP._f1e�� TEIJ'��"i'��.f REAR ❑ p APPIICANT T�L SIDEiSIDE STREET RW ❑ _. z ¢ CONTRACTOR /"�S W SIpE � � ADDFtESS � PROPOSED USE F G�v -� CI1Y �� Z�P.��L TEL.�� - w ARGH/ENGI ^'� z pESIGNER NO.DWEL. '� + . NO. � AdDRESS �_ - UNITS I SSORIES � BEpROOMS � CaTy ZIP TEL_ � DESCRIPTtON SQ.FT. FACTOR PSF ADJ.AREANAlUAT14N cr� � OWN£R-BUILDER OECLAftAT40N SFWA4DIREM a � t HEREBY AFFIRM UND_ft PENALTY OF PEH.IUHY THAT 1 AM FXEMPT FROM THE CONTRACTORS LI� G2f89B/C8(pOfl W CENSEIAWFORTHEFOLlO1NINi3REA50N(SEC.lD9i.58UStNE35ANDPROF€SSIONSC6�E�.ANYCI2YOfl (J} �� COUNTVWHICNREOUIRESAPERMITTOCONSTRUGT,ALTER,IMPRUVE,DEMOLISN,ORPEPAIPANYSiRUC. W Pdf10/DeCI( � 7URE,PRIOft TO iT5 ISSUNlCE ALS6 R£4ltIPES THE APVUGANC FQR SUCN PERMIT TO!'11.E A SIGNEU � � 3TATEMENT THAT HE OR SNE IS LICENSE�PURSUANT TO TNE PPOWS�ONS 4�mE CONTRACTORS Li� � CENSE LAW(CHAVTER 9(COMMENCING WITH SEC710N 70ptl)OF DIVISIQN 3 Or THE 6USINESS AND PRO� � PaoVSpa .� FESSIONSGODE}ORTHATYE6ftSHEISEXEMPTTMEREFROMANPTHEBASiSFOflTHEAILEGEDEXEMP� � TpN.ANYVIOLATiONOFSECTION7D31.5BVANVAPPLICANTFORAPERMRSU6JEC7STHEAPPLiCANTTO Z Re-Rooi � AGVI(.PENAI.TY OF NOT MOflE THAN FIVE HUNOFlED DOLLARS�S5o0).)'. ,� I7LASOWNEROFTNEPROPERTY.OR�.IYEMPtOYEESWiTHWAGESASTHEifiSOIEGOMPENSAT40N, � �O(fl(it8(Ct31 � WIIL C16 THF.WORK.AND THE 5TRUCT'URE IS NOT INTENpED OFl OFFEREO FOR SALE;SEC.7obd,BU51� J � t�SS AN6 PROFESSION5 CODE:THE CANTRAGTORS UCENSE lAW D6E5 N(7'f APP4Y TO AN OWNEF OF � PROPERTV VJI�10 BUIIDS C/R IMPROVES THEREON,ANO WHO�OES SilCH WORK HIM5ElF ORIiERSEtF�fl ('r THROUGHHISORHEROWMEMPI,OVEES.PR(7VIDECITHATSUGMIMPRpVEMENTSARENOTINTENDEDOR � � OFFEREDFOftSALE.iF,HOVfEVER,THERtAtDiNG4ftiMPftOVEAbENTt55U19WlTHiNONEYEAflOFOOMPIE�� TION,THE OWNER�BUILpER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DiD N07 BUitD OR � IMPRDYE FOfl THE PURP6;:E Of SALE}. �yy C.Ii,A50WNENOFT7it:PAOPERTY,AMEXCIUSivEtYC04TRACTiNGWiTHUC£N5EQCQNTRACT4ft5 F-r�,.„ jj G+r/� ADJ.AREA___ [L TO CONSTRUCT THE PR4J'=GT(SEG.7oa4,BUSINESS AND PROFESSipNS CODE'.THE CON?RACTOPS LI- V8IU8tiOf1 � W CENSEL4WpOE5NOTAPPLYTpANOWNEROFAPfiOPER7YWHOBUILDSORIMPROVESTHEREON,AND � WHOCANTRACT$FORSUCHPROJEGTSWITHAGON7RACT6RtS}UC£NSEDPUASUAMT6THEGp*lTflAG Q(fARITI�CY DESCRIPTION �EE x TORS LICENSE LAW). � � ❑I AM EXEMPT UNpER SEC.` B.8 P C.F�R THIS REAStSN Q U � '—. Q L�' DATE __ _ oWNEP._....—. .. .--_.�' U � _ W Q LICENSE�CONTRACTORS DFCLARATION � � w CC I HEREBV AFFIRM UNOER PENAI,.TY OF PER.IURY TMAT i AM UCENSE6 UNDEP PFOVtStONS 4F CHAPTER �e (i 9(C06/MENCING WITH SEI:TION 7000)pF DIVISION 30F TNE BUSINESu PND PROFESSIONS CO�E,AND Z �X MY L.ICENSE IS 7N FUlL F4RCE AND EFFECT. m � � LlCENSE C S 'G-� �� I,IG.N6. � �� ._ � U DATE_s�_ � GONTRACTOR . .�.. d ..— W f� WOFIKERS'COMPENSATION pECLARA a � U � I HEREBY AFFlRM UNDER PENAI.TV O'r PEqJURY ONE OF iHE FOltOwiNG OECtARAtiONS: Z �,/ Q Zy I HAVE ANU Witl MAINTAiN A CERTit'{CATE 4F CQNSENT TO SEtFINSURE FOfl WORKERS' � � CAMPENSATION,AS PROVI�ED BV SECTION a]o00F TNE LABOR COOE,FOR THE PERFORMANGE W OF TH£WOFK FUR WMCH SN15 PEftMiT 15 iSSUED. �, 0 w 1 HAVEAND WILI.MAINTAIN WQRKEfiS'COAAPENSATION INSJRANCE,AS FEC1l:IREp BY SECTION � Q 37060F THE LA809 CPOE,FOFL TNE PERFORFAANCE QF THE W6Pof FQR WNICH THIS PEMAIT IS _ ' —�' L ��' IS$UED.MY WOFMERS'CAMPENSA N IN5UR CE CAPRIEa ANO POLICV NUM6ER ARE: CONSTRISCYION �_-- � CARRIER��_-'C3dl.�.� .— _.__ ��1�ftEVI�Y'/ .._.... ... _ —. Z PQUCY NUMBEP_��'?.�.,,,,..��._ .... .... ELEC7�RIG � .—... ¢ (lHISSECiXN1NGmNOTBECC'MFLEfEDOF'�}�EPERMf1�5FOFONEHUJI7RED00l.LM5�E1ao)ORL[SS). PLUMBING � Q —......._� w I CERTIFV THA7 IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSLiEO,I MECHANICAL __,_, �— Z (,*} SHAIt NdT£MPLOY ANY PEHSON IN nNY MaNNER 54AS TO BECOME SUHJECT TO THE (NSPECTiON FEE � WORKERS'COMPENSAT�ON LAYlS OF CA4�F�ftNiA N6 AGREE THAT IF t S!i�ULO BF��OME . — �;"�—'— � SUBJECTTO THE WOHNEFS'COMpENSAT OVIS S OF SECTION 3]Oc OFTHE L4BOR ISSUANGE _ ..-- � COp,tSH IIORTNWiTHC4MPtYWi THOSE ROV! ONS- —�� O ' 5MIP �y DATE:_.. �/�.. APPIICANT: .— ..- , �—.. w .. ENERGY P1C ` ... —� WARNING:FAILIIflETO SECURE WORKERS'COMPENSATION COV GE IS UNLAWFUL,AND SNALL BE "' � � SUBJECTAN EMPlOYE4;T4 CRIMINAI PENALTIESANO S:.lYiL FlNES UP TO ONL NUNDRED THOU3AN0 LL DOLLARS(f��.000�,IN ADDITION TO THE COST 6F ODMPcNSAitON,OAMA6ES AS PROVIDED£6R M ENERCaY PE.RMIT ,,, � SECTION9�o80GTHElABoqCODF.INTEflEST.PNDATfORNEV'SFEES. RETENTIONFEE: ^ .. ��-- � GONSTRUCTIQN LENDING AGENCY PRE-ALT FEE: .-- — O � I NEPEBYAFFIqM UN��R PENALTY pF PERJURV THA1 TMERE IS ACONSTRllCTlON LENp;NG AGENf.Y _ ,_ ...._ � FOii THE PERFORMAW:E OF fHE WORK fl7R WHICH TNIS PERMIT IS ISSUEp(5[C.J09],CIV.C.). Z _ _�...— W 2� LENDER'SNAME_.__ . —......— ....'--.._ .... ._.. ., , — F_ LENDER'SAD�FlESS__.,.._,,._— ._---�----- � TC}TA�FEES / ,� ��`"� � 1 CERTIKV THAT I HAVE REA[1 THIS APPL�CATION AND S7ASE THkTTH[ABOYE 1NFQRMATIOM1 IS CORRECT. 1 � W I AGREE Tp COMPLY MIRH ALL CITY AND COUNTY ORUINANCES ANq SrAT[LAWS RELATING 1(7 BUILCIING � CONSTRUCTION,ANO HEREBY AUt'HOR�ZE REPftESENTATfVE5 OF THVS CGVNTY TO EN1ER UPON THE ZABOVE-MLNTIONED PROPEFTV FOfl IN PECTIOM P OSES. COMMENTS ... � ------'�G"' �� _ ..—. — � ` ' .. ..... ... _ .' . _._—_ —�. � RERMiiTEE hAME � "" ' ¢ _ — U7 . . � .— '--_ - '— � SIGNATU F� 6ATE� '� ? "�� J�� iiECPT.NO. PAiD BY L;�. r � VALIDATION=_!` Z -- ~ ,, �� WHITE—Department Copy,�'EL�OW—Finance CopY,PiNK—Assessor Copy,GOIOENfiOD--File Copy.GREEN—AppliCan4's Gopy i'�T =� w�i='�� ,�� r� �� '��' � . . . � ... �.r.,�� e,�� . .. �a.��.� . . . � - .. ... .. ��d L �f'�"'\ Z�� J'� . � �� _ � '" �� '.^, 'a ��_ _ _ _ _ �, r "� �� . , . ., ., ., ,,. �, "�a .�.�y.�.`. �. , , ..... . ... . . . ... � ; � . ... _. .... . .. ..... . . ,. ._ .-. '. � n,a r.�o � . . . ... .. . ..... ._ _ ,J -S e.r a'�. ._ . ..... . . .. . � � •3 � ��k ` ' .. _.. _ . . . . . _ . . . ... . .. ... . ._.. . „ �r„� n _7 ''`�,. �'a ..._ ._.. . .. ... w�a �� r. �� ,- � . r�.�',�. . � ,. .;_ � .. ._... .. . ._. .. _. . .. . � , , _ � . .. . ... .._ . .. _. ... . ... . .. . . .. ..... ._.. , �. , � �.a a . .... ... �, 1 ` t� : ��. , �= i �� . d . ... .. . . . .. . . ,. , , ... .. .. . .. � �"` °�., � dy.:J s, d � —. .. ...... .. ... . . ... .. . .< < . �..,..mr. . �{ . . . . _. .. _. . . . . . . CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Ihive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION �f: PRESS FIRMLY ADDRESS�i"�y G/ APN� LOTTRACT OWNER %�� 7�.- - -- CITY��-�fJ/�a ZIP��a TEIy�'�7'�-1�7.f APPLICANT TEL. CONTRACTOR/�3� ADDRESS��/ CITY_��T/f L(-�-ZIP . �TEL. ARCH/ENG/ DESIGNER ADDRESS_ CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLOINING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC- TURE,PRK)R TO ITS ISSUMICE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSELAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO FESSIONS CODE)OR THAT H E OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500}): ^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH 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 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 IMPROVEMENT IS SOLD W ITHiN ONE YEAR 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). ^I,AS OWNER OF THE: PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSELAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUC H PROJECTS W ITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). ^ I AM EXEMPT UNDER SEC. B.8 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 AND EFFECT. MY LICENSE IS IN FULL FORCE �S} ��,�( cQ�� L LIO_N0./v' LICENSE C S DATE' 1 CONTRACTOR WORKERS'COMPENSATION DECLARA 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 PROVIDED BV SECTION 37000E 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 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WOFIKERS'COMPENSAT N INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER�t�c�I'�L�J,/ o� POLICY NUMBER I ��/ ([WSSECTION NEED NOT BEOJMFLL7ED OF THE PERMLi IS FOR ONE IIUNORED DOLLARS(EtOD)ORLESS} I CERTIFY THAT.N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA ND AGREE THAT IF I SHOULD BECOME -SUBJECT TO THE WORKERS'COMPENSAT OVIS NS OF SECTlON 3700 OF THE LABOR COD I SH L FORTHWITH COMPLY WI THOSE ROVI IONS. i DATE:V�APPLICANT: I I WARNING: FAILDRE TO'SECURE WORKERS'COMPENSATION COV GE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THWSAND DOLLARS(5100 000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES. I CONSTRUCTION LENDING AGENCY i I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRVCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.j. I LENDER'S NAME LENDER'S ADDRESS I 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY V/ITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE S ABOVE-MENTIONED PNOPERN FOR IN PECTlON P OSES. 1 J 7� � PERMITTEE NAM F T) �SIGNAT F DATE a 0 0 LL 0 w z 0 0 cn U F- Z fS W Z W Q W 2 H ]G Q 0 11 Z 0 Q X W 0 U w N Z Q 0 W Q Q D Z Q W Z WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy z1A