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Home My WebLink About12004CITY OF DIAMOND BAR / - DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES ' J 21660 E. Copley Drive Suite 190 / (909)860-3195 Fax(909)861-3117 PRESS ".A BUILDING PERMIT APPLICATION FIRMLY JOBSITE ADDRESS. LARK 9�1� _ # ISSUE APN LOT TRACT OWNER ADDRESS - CITY i7� ZIP i TEL. APPLICANTT�16EL CONTRACTOR 44U4211r, Heftt-r ADDRE S Fi ozz CITY -z ' ZIP /' --�7TE �-ARC FRONT DESIGNER) ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 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 REOUIRESAPERMITTO CONSTRUCT,ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 L6 CENSE UW (CHAPTER 8 (COMMENCING WITH SECTION 7000) OF DIVISION 30F THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE. OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (11500).): 171, ASOWNER 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. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DCES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, 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 HOWEVERTHE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT NE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE) L3 I, AS OWNER OFTHE PROPERTY, AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHOCONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC- ONTRAOTORS TORSLICENSE LAW.). ❑ IAM EXEMPT UNDER SEC. _,--_ B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER S (COMMENCING WITH SECTION 7W0) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO.+ DATE 'P �__ CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS 4 I NAVE AND WILL MAINTAIN ACERRFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. —1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WOR INSURANCE CA IER AND POLICY NUMBER ARE: TION CARRIER ✓ i'Fp C POLICY NUMBER UMsECRDNWEDNOTBE OFTtEPEFMITOFORCNEKAVFtEDDOl1AA3($100)DRLESS) 1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME - SUBJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE SHAAALLL%}}}FORTHWITH COMPLY WITH TT BE PROVISIONS. `/�a, DA7E: �,( APPLICANT:�/�,,,. WARNIN - 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 (6100,000). 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 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. 3087, CIV. C.). 1 LENDER'S NAME ___.._____._.-_....___ LENOERSADDRESS _--_._._-..------------- I CERTIFY THAT I HAVE READ THIS APPLICATION AMU STATE THAT THE ABOVE INFORMATION 15 CORRECT ( I AGREE TO COMPLY WITH ALL CRY 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 INSPECTKNI PURPOSES. PERMITTEE NAME(PRINT) r ,y7 P T SIG TU OFPERMF ISS,DAT G APPLICATION t' " 10 '1 PERMIT -0 /C DATE y NUMBER _ # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW n REAR ❑ SIDEISIDE STREET RW Ll _ SIDE F3 PROPOSED USE r ' h1jz NO. DWEL. NO.11 NO. UNITS STORIES �� : BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM Garage/Carport W Patio/Deck L- POOVSPa Z Z Re -Roof _, --Drb Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U - lr H U UJ w w z Z -� m d I� • Z Q U w CONSTRUCTION _..... _...... —_....._....__.. PLAN REVIEW ____......... ELECTRIC PLUMBING , MECHANICAL INSPECTION FEE ISSUANCE"" - SMIP ENERGY P/C ......_. ._. _ ENERGY PERMIT __.., ,._....._ RETENTION FEE: - a PRE -ALT FEE: TOTAL FEES COMMENTS _._._... v RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLUENHOD—hDe Copy, UHEEN—Appucanrs copy