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Home My WebLink About18153 �,� CTI'Y OF DIAMOND BAR � 1 �.� �� DEF'ARTMENT OF COIvA�iIJNTi'Y&DEVELOPMENT SERVICES � ;,;� 21825 E.Copley Drive �} _`� (909)860-3195Fax(909)861-3117 � �U PRESS ��'<�r BUILDING PERMIT APPLICATION FIRMLY JOBSITE ��- ApPLICATION r ADDRESS�I 1 Z�i, � _I J��, �� `��'� PERMIT �;t ; d � P/C o DATE '� .7'�NUMBER �� % �g ^° APN LOT TRACT ISSUE TYPE OCC p OWNER �Ci' DATE CONST. GROUP ADDRESS Z�' Z� � ZONING SETBACKS W CITY T ZIP ' . �TEL. '-�> 1 FRONT Ryy � � APPLICANT 'l.iE. TEL. �!i ' :3=3[i REAR � � A SIDE/SIDE STREET RW ❑ m CONTRACTOR � - � __��i'v�zs�; SIDE � ¢ ADDRE�yS��7�� t � � r�r� � CITY�--�y��-`-�- ZIP TEL. .�`� PROP��jjj S��ED��SE LK-u.'/�. � � < 1 � 7D o ARCH/ENG/ �!`/� � �" z DESIGNER ��1: �` L a ADDRESS NO.DWEL. N , ' NQ � CITY ZIP TEL. UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECL4RATION O SFR/A�D/REM p I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM F%EMPT FROM THE CONiRACTORS LI- G8f8J8/C21pOft W CENSELAWFORTHEFOLLOWINGREASON(SEC.]oa1.58U51NESSANDPROFE5510N5CADE:AM1VCITYOR (n U COUNTVWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE.DEMOlISH,ORREPAIFANVSTRUC- Pat10/DBCIC w Tl1qE,GRIOR TO ITS ISSVI\NCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNEO W STATEMENT THAT HE OR::HE IS LICENSE�PURSUANT TO TME PROVISIONS OF THE GONTRAGTOR$LI- w � CENSE LAW(CHAPTER e((bMMENqNG WITH SEGTION 1000)OFOIVISION 3 OF THE BUSINESSAND PRO- � POOUSPB O FESSIONSCODE)ORTHATHEORSHEISEXEMPTiMEREFROMANOTHE8ASI5FORTHEALLEGEDE%EMP- � V TION.ANYVIOLATIONOF5I=CTION�a31.5BYANYAPPLICANTFORAPERMITSU&lECTSTNEAPPLICANTTO Z Re-Roo1 � /y � A CIVIL PENALTY OF NO7 MORE THAN FNE HUNDRE�DOLLARS(S5o0).)� J �� 0 ❑I,ASOWNEROFTHI:PFOPERTY,ORMVEMPLOYEESWITHWAfESASTHEiPSOLECOMPENSATION, � GORIrt18fC181 Z WILI DO THE WORK.ANO 1-HE STRUCTl1RE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.�Oad,BUSI- J � NESS AND PROFESSIONS I:ODE THE CONTRACTOFS LICENSE LAW DOES NOT APPLY'O AN OWNEP OF j VROPERTY WHO BUILOS ON IMPROVES THEREON,AM1D WHO DOES SUCH ydORK HIMSELF Ofl HERSELF OR � THROUGHHISORHEROW!JEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m QOFFFREDFORSALE.IF,HOWEVER,iHEBUILDINCaOFIMPROVEMENTIS50LDWTHINONEYEAROFCOMPLE- . Z TION,THE OWNER-BUILDEN WILL HAVE TNE BURDEN OF PROV�NG THAT HE OH SME�I�NOT BUILD OR � IMPROVE FOR THE PURPO;iE OF SALE). w ❑I,ASOWNEROFTHI=PROPEFTY,AMEXCIUSIVELYCONTRACTiNGW1T4LICENSEDCONTRACTORS � TO CONSTRUCT TME Pq0.1ECT(SEC.�014,BUSINESS AN�PqOFE5510NS CODE'THE CONTRACTORS LI- V3luefiOn 11DJ.AF3EA W CENSELAWDOESNOTAPFLYTOANOWNEROFAPROPERTVWHOBUIL�SORIMPROVESTHEREON,AND � WHOCONTFACTSFORSUCH7ROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAF QUANTITV DESCRIPTION FEE Y TORSLICENSELAW.). QC I AM EXEMPT UNDER SEC._. B.&P.G FOF THIS HEASON Q � U � DATE OWNER � � LICENSED CONTRAGTORS DECLARATION W � I HEREBYAFFIRM UNDEfl PENALTV OF PERJURV THAT IAM LICENSED UNDER PROVISIONS OFCHAPTER � 2 9(COMMENCING WITH SEC�ION]000)OF DIVISION 3 OF THE BUSMESS AND PROFESSIONS CODE,AND Z 'X IAV LICENSE IS IN FUIL FOF.CE AND EFFECT. k ^7 m � LICENSErC'L,A'SS�!��_ LIC.NO. C� / (� �•�i�( V DATE sy�_�� CONTRACTOR F-��lV I W � � WORKERS'COMPENSATION DECLAqATION Q � I HEREBV AFfIRM l,'NDER PL'NALTV OF PERJURY ONEOF THE FOLLOWING OEGLARAfIONS: � � Z � IMAVEANDWILLMI\INTAINACEFTIFICATEOFGONSENTTOSELF-INSUREFORWORKERS' a Z — _ Q COMPENSATION,ASVROVIDEDBYSECTION3]OOOFTHELABONCO�E,FORTHEVERFORMANCE U OFTHE WORK FOR WNICH THIS PERMI'IS ISSUE�. W � — I HAVE AND WILL MNINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BYSECTpN � Q 3100�F THE LA60FI CODE,FOR TNE PERFOPMANCE OF THE WORK FOR WHICH THIS PERMIT IS � I � ISSUED.MY�/RKjE�RS'COMPE�NSrATIONA INSUFANCE/CARnRIE,R—�Jrt�POY CV NUM9ER ARE� CONSTRUCTION �� , `'�I1.� j CARRIER ` I1 �N I/T `"� A..K-GI `�/ PLANREVIEW zPOLICV NUMBER�„�L ii ' ��'�� Q ELECTRIC __ 0 (iHIS5ECT10NNE�IWTBEOJMPLEfEDOFTHEFEFUNiISWRIXJEHUI�OREDDO�IAq$($ippJORLESSj. PLUMBING W Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS iSSUED,I MECHANICAL U SHALL NOT EMPLOI'ANV PFRSON W�W V MANNER SO AS TO BECOME SUBJECT TO THE �/J WOFKERS'COAIPENSATION LAWS OF CALIFORNIA,ANDACR E THAT IF I SHOULD pECOME INSPECTION FEE � SUBJECTTO THE WORKERS'COMPENSATIvN PROVISIONS SECTION 3]OOOF THE Lr1BOR -- ,�—�,-�— � ODE,I SHALL FOR�HWRH COMPLV WIT THO E PR� I� ISSUANGE - . � q� p OATE: V _ qppLICANT � SMIP � W J WARNING�FAILURETO SECIJqE WORKE 'CO ENSATION COVE AGE IS UNUI ,AND SHALLBE ENERGY P/C J � SUBJECTANEMGLOVERTOCRIMINAL.ENALTIE ANOCIVILFINESUPTOONEHUNDRE�THOVSAND ENERGVPERMIT DOLLARS�floo,o00),INADOITIONTOT ECO FCOMPENSATION,DAMAGESASPROVIDEDFORIN J SECTION3loeOFTHELABaRCODE,MT EST,AN�ATTORNEV'SFEES. RETENTIONFEE: � W _— O CONSTRUCTION LENDING AGENCV PRE-ALT FEE: � I HEREBVAFFIRM UNDER PI:NALTV OF PERJURY THAT THERE IS ACONSTAUCTION Lc'NDING AGENCY FOR THE PERFORMANCE O��THE WORK FOR'rVHICH THIS PERMIT IS ISSUED(SEC.309),CIV.C.f. --- Z W � LENDER'S NAAAE H �ENDER'SADDRESS � TOTAL FEES + ' �; i� � I CEPTIFY TNAT I HAVE READ THISAPGLiCATIONAN�STATE T/.AT THE ABOVF INFORMATION IS CORRECT. � '�, w I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCCS AND STATE UWS RELATING TO BUILDING 1. J � � � I � CONSTRUCTION,AND HEREBVAUTHOFIZE REPRESENTATNES OFTHIS COUNTYTO ENTER UPON THE " Z A VE-MENTIONEO FROPE9TYFOR INSPECTION URPOSES. COMMENTS � ��' � ,'L U�/��7 l� -- m P EE M NT� � �� Q �V � I� � SIG ATUREOFP MITTE ( � ......--.— OATE �. .s � � " , � � RECPT.NQ - PAID BY ��1 ^-+ ' VAL�OATION - -� WHITE-Oepartmen�Copy,VELLOW�inance Copy,PINK-Assessor Copy,GOLDENRO�File Copy,GREEN-ApplicanCs Copy . , , 6k w # ��^� Y w�'a�+ � r ��, �P� . ��. .��" �'t ' ,ti�: o _ .,. , . 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F im`�� fa�$r._'��. 5�`'..� . ,.".'� q a�s'�,.5�°�-�r ' .... CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE I A n ADDRESSh 112L%--tr'CDR APN LOT TRACT OWNER LG'E ADDRESS CITY D A J'> ZIP TEL. --0. 1 APPLICANT I1 TEL. &� 7-0-G CONTRACTOR)-0-JC) ADDRES CITY(It�t�ZIP TEL. .f>5 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 CITYOR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,OR REPAIR ANY 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(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 ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($5001)' EI I,AS OWNER OF THE 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 OH 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- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). ^ I AM EXEMPT UNDER SEC. B. &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 MY LICENSE IS IN FULL FOFFCE AND EFFECT. �-7-3 LICENSE CLASS{E� 1N�-- LIC to•3 NO i DATE CONTRACTOR F-�LIV 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 PROVIDED 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 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS YN(OR ERS'COM ENSATIONINSURA ISSUED. (RRICY NUMBER ARE' 1 CARRIER fl/a ER POLICY NUM13E R te Ir3drl (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOIJARS(5100)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 SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGR E THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS SECTlON 3700 OF THE LABOR CODE. I SHALL FORTHWITH COMPLY WIT THO E PR I // DATE:APPLICANT / FAILU RE TOSECURE WORKE'CO ENSATION COVE AGE IS UNIA,AND SHALL Be WARNING: SUBJECT AN EMPLOYER TO CRIMINAL ENALTIE AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000),IN ADDITION TOT E CO F COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INT EST,AND ATTORNEY'S FEES. CONSTRUCTlON 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.). LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 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 A VE-MENTIONED PROPERTY FOR INSPECTIIONN UURPOSES.A I } e. 4UIYv��VA EE M NT) G ATUREOFP MITTS DATE I APPLICATION PERMIT P/C DATE^ �� 'i UMBER# ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE^ PROP SED USE 1F•C 1 ti b it) 1Z?KVL-M N0. DWEL. N . N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM W Garage/Carport W Patio/Deck LL Pool/Spa 0 Re-Roof �I Cy Z Commercial co Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U U W 0 Q Z S U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT. N0. '- PAID BY La) 1 VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy 11