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Home My WebLink About15112 (17)UI,I�IIIJU Ii�lRl� 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 KI APN LOT TRACT OWNER ADDRESS 100II-4am CITY'; A) c ZIP' TEL. L -� � APPLICANT TEL. CONTRACTOR _ ' cr ADDRESS7' L_3=,, 7 ilf CITY �r ':•Ls_��r ZIP"� CL. TEL. Sid arE'�t�J 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- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESAPERMRTO 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 LI- CENSE LAW (CHAPTER 0 (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 EXEMP. TION, ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 0 I, AS OWNER OFTHE 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 OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THATSUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN 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 CONTRACTING WITH LI,SNSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7041, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO GUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTO THECONITRAG TORS LICENSE LAW.). D I AM EXEMPT UNDER SEC. B. A 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 e (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CCDF, AND MY LICENSE IS IN FULL FORCE AND EFFECL LICENSE CLASS ��LIC. NO. DATE�..�� CONTRACTOR__ WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: —I HAVE AND WILL MAINTAIN A CERTIFICATE OF C.ONSENTTO SELF -INSURE FOR WORKERS' COMPENSATIOR AS PROVIDED BY SECTION 3700 OF )HE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITS ISSUED. —1 HAVE AND WILL MAINTAIN WORKFRS' COMPENSATION INSURANCE. AS REQUIRED SY SECTION 37000F THE LABOR CODE, FOR T'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' OOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIERp'�,`+�""-+1�-'�']dL._�'�'"S POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED OFTFE PERMIT G FOR CNE HUNDRED DCIIA S (3100)OR LESBL I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSI )ED, i SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSA OON 3700 OF THE LABOR CcO,D.E{,1SMALL FOR THWITH COMPLY I THOSE PROVISO DATE: `� `a �°"� APPLICANT:_. tt ____ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100.000), 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 1 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. 30.7, CIV, C:). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 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 -MENTON D PflOPERTY FOR INSPECTION PURPOSES. i — PERMITT E (: RINT) 3 SIGNATUREOFPER77i f1TEE"�"— DATE f'a e PRESS FIRMLY APPLICATIO PERMIT DATE - NUMBER # # � �L ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS — STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM W Garage/Carport WPatio/Deck U- Pool/Spa ZRe -Roof 0 Commercial 5 M Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J V 2 U Lu W Z m J U Z 2 W CONSTRUCTION PLAN REVIEW ELECTRIC - PLUMBING ^� t3;;yypp�� MECHANICAL IRI�O 1 P; 6100 26100 y tJ _L_ INSPECTION FEE 91A CITY ISSUANCE CI t Y Q- 1$i 1i(. pjNrj PL,ND be 4`I Sad. SMTP ENERGY P/C ENERGY PERMIT RETENTION FEE: — PRE -ALT FEE: TOTAL FEES COMMENTS RECPT NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finanoe Copy, PINK—Assessor Copy, QDLDENROD--File Copy, GREEN—Applicant's Copy