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Home My WebLink About15054 (20)UI,I�IUSU BAR i CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS APN LOT TRACT OWNER M*% ADD� SS 2,gb—k_Y-ro4i-j- CITY Pis 4'k'- ZIP TE4_0 a 1-7 APPLICANT M'kV, AQy J TEL. _ CONTRACTORbQ'LQ,C-a, f ADDRESS is CITY JAIL YL ZIP TEL. — ARCH/ENG/-,, DESIGNER .lhc'S�L-l& __Z�(.. _ ADDRESS kJpoc CITYZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U - CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESAPERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLIS11. OR REPAIRANY STRUC- 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 LI- CENSE LAW (CHAPTER 9 (OOMMENCINO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPTTHEREFROM ANDTHE BASIS FOR THE ALLEGED FXEMP• TION. ANY VIOLATION OF SECTION 7931.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).); ASOWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL 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 HIMSELFOR HERSELF OR THROUGHHIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD V41THIN ONE YEAR OF COM KNIPLE- T- THE OWNER WILL HAVE THE BURDEN OF PROVING THAT IIF OR SHE DID NOT DUILU OR IMPROVE FORTHE PURPOSE OF SALE). r.11, AS OWNER OF T1 `E PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO'THE CONTRAC TORS LICENSE LAW.). ❑ IAM EXEMPT UNDER SEC. - _— B- 8 P.C. FOR THIS REASON DATE LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS— - LIC -NO. DATE—. CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATK)N, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE. OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. _.--I HAVE. AND WILLMAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 37W OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARF: CARRIER POLICYNUMBEH (R955ECITUNNEFD NOT BEOOMRETEDOF THEPERMTTIS FOROHEHU DRED DOLLARS($100)OR 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 SOAS TO BECOME SUBJECT TO TI IE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO T HE WORKERS' COMPENSA,TIUN PROVISIONS OF SECTION 3700 OF THE LABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: -- APPLICANT: _..—__._....._— __._._..—____._--- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL HE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,0D0), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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,). I LENDER'S ADDRESS -- -- I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT' THE ABOVE INFORMATION IS CORREC r. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING i CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTERUPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. 1 ` — � P R ENA T) ) /,q V� SGNA HBO PERM, E PRESS FIRMLY APPLICATION -2,01()() PERMIT �lf/ P/C O DATE NUMBER -_ (j/ ISSUE ^ / J TYPE p OCC f CONST GROUP _ ZONING SETBACKS FRONT RW REAR ❑ _ SIDE/SIDE STREET RW O SIDE LI p OPOSED USE o— NO. DWEL. NO. NO. UNITS STORIES _ BEDROOMS DESCRIPTION SO, FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport WPatio/Deck V- PooVSpa '-,•oi 0 Z Re -Roof QCommercial 5 m VBlDaticn ADJ.AREA QUANTITY DE 'RIPTION FEE Q / / U U W LU QA ems, — 1 2 LUU -- CONSTRUCTION all 2 ��_(` _ _ PLAN REVIEW _. -,. '.:,-. ... L ELECTRIC --VVV-- - z ...::...•. =-' PLUMBING MECHANICAL .- INSPECTION FEE ISSUANCE SMIP ENERGY P/C r '" ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: MV 1 051 TOTAL FEES 7 ) U COt�f/ENTS�1__r_9 1 RECPT. NO. --- PAID BY .--- — VALIDATION —Vy WHITE --Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy