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Home My WebLink About17674 , �� CITY OF DIAMOND BAR � DEPARTMENT OF COIvIlviUNT['Y&DEVELOPMENT SERVICES �"�,��-� 21825 E.Copley Drive (909)860-3195 Fax(909)861-31 l7 �� PRESS BUILDING PERMIT APPLICATION � FIRMLY o ADDRIESS ZI b�� UI�Ir("I �1•) �I A �� DATEICATION I� �� PERMIT J r,.� p/C � NUMBER U� # � ISSUE � ,�J TYPE OCC APN C LOp TRACT DATE �� -•� CONST. GROUP p OWNER o ADDRESS _ ZONING SETBACKS z C�N ZI TEL. ' FRONT RW ❑ � APPLICANT TEL. �� REAR �j z -- SIDE/SIDE STREET RW ❑ ¢ CONTRACTO _ SIDE � ADDRESS � � C�T�' �ILt' ZIPQ(7�P�I TELqjL PROPOSED USE r o ARCH/ENG/ �""" � z DESIGNER d ADDRESS NO.DWEL. NO. NO. cn U N ITS STDRI ES BEDROOMS � CITY ZIP TEL. � DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM UNDER PENAL7V OF PERJURY THAT I AM E%FAIPT FqOM THE CONTRACTORS L6 GBfdJB/CBfPOft W CENSELAWFORTHEFOLLOWINGREASON(SEC.]031.SBUSINESSANDPflOFESSIONSCODE:ANYqTYOR (n U COUNTVWHICHPE�UIRESAPERMITTOCONSTRUCT,ALTEP,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- w TURE,PRIOP TO ITS ISSUANCE,lLL50 REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED W Patio/Deck � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE GONTRACTORS LI� � CENSE LAW(CHAPTEfle(COMMENGING WITH SECTION�D00)OF DIVISION 30F THE OUSINE55 AND PRO- � POOUSPB � FESSIONSCOOE)ORTHATHEORSHEISE%EMPTTHEFEFRDMAN�THE6ASISFORTHEALLEGEDEXEMP- (7 U TION.ANYVIOLATIONOFSECTION7031.SBYANYAPP'JCANTFOFAPEFMITSU&lECTSTHEAPPLICANTTO Z Re-Roof A pYIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(S50o;�,): � ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHFIRSOLECOMPENSATION, � CDmmBfCial Z WILL DO THE WORK,AN�THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.]O4C,BUSI- J � NESS AN�PROFESSIONS CADE:THE CONTRACTOHS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � GROVERTV WHO BUILOS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF Oq W THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHqTSUCHIMPROVEMENTSARENOiINTENDEDOR m Q OFFEflE�FORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTIS50LDWITMINONEYEAROFCOMPLE- Z TION,THE OWNEF-BUIL�ER WILL HAVE TF1E BURDEN OF PROVING T�IAT HE Ofl SHE UI�NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE). w uI,A50WNEFOFTHEPROPERTY,AMEXCLUSNELYCONTRACTINGWITHLICENSEDCONTRACTORS }'� � TO CANSTRUCT iHE PRQIECT(SEC.7o4a,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V31U0fI0n ��J L]• ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND . FWHOCANTRACTSFORSUCHPRQIECTSWIiHACONTRACTOR(5)LICENSEDPURSl1ANTTOTHECONTRAC- QUANTITY DESCRIPTION Y TORS LICENSE LAW). FEE O ❑I AM E%EMPT VNDER SEC. 0.8 P.G FOR THIS REASON ¢ � U � �ATE _..__ OWNER H , Z U � LICENSED CONTRACTORS DECLARATION w a Q I HEREBYAFFIRM 11N0ER PENALTV OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CNAPTER � d 9(COMMENCING NATH SECTION]000�OF DIVi510N 3 OF THE BUSINESS AND PROFESSIONS COOE,AND Z X 1AV LICENSE IS M FULL FORCE AND EFFECTr I_ � LICENSE CLAS�"-I 1 �( v LIC.NO. O V � � V DATE_�y� T� CONTRACTOR. • � W � WORKERS'COMPENSATION DECLARATION Q � IFIEREBYAFFIRMUNDERPENALTYOFPERJUFYONEOFTHEFOLLOWING�ECLARATIONS: Z � IHAVEANDWILLMAINTAINACE(iTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' ¢ Z CAMPENSATION.AS PflOVIDE�BY SECTION 3]ooOF TME IABOR CODE.FOR THE PERFORAIANCE U Q OFTHE WORK FOi1 WHICH THIS PEAMIT IS ISSUED. � Qw �I HAVE AND WILL MAINTAIN WOqKEF75'GOMPENSA�ION INSVRANCE,AS REQUIRED BY SECTION n ^ 370o OF THE LABOfl C��R TH�ERFORMANCE D�THE WORK FOfl WHICN THIS PERMIT IS � ` 7 /� ISSllEO.MY WORNERS P 1 ON INS��n c RIER AND POLICY NUMBER ARE� CONSTRUCTION �/( J � CARRIER � I� PLAN REVIEW Z POUCVNUMBER_ ELECTRIC ¢ � (iHI55EGT%7NNEmNOTBEWMPLEfEDOFTNEPERMITISiORIXJEMNAREDDOLLARS(E7[0)ORLESSi. PLUMBING _ W Z 1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH HIS FRAAIT IS ISSUE�,I MECHANICAL (�J SHALL NOT FMPLt)Y ANV PERSON IN ANV MANNEF SO AS T ME 5 JECT TO THE N WORKERS'COMPENSATION LAW LIFORNIA, NDAG EE AT IF I HOULD BE E INSPECTION FEE � SUBJ CTTO HEWORKERS'COMP SA ONPRO ISION OFS TION3000FTH OR . COD S FORTHWITHCOMPL WIT TH SE R IS NS. ISSUANCE � 1\ . T p DATE:� v� APPLICAN ____ SMIP U � W J WARNING:FAIWRE TO SECVRE WOFKER' OMPENSATION COVERAGE IS UNLAWF , ND SHALL BE ENERGY P/C J LL SU&IECTAN EMPLOYER TO CRIMINAL PENALTIESAND CINL fINES UP TO ONE HUN E THO�SANO ENERGY PERMIT DOLURS(S1Do,000�,INADDITIONTOTHECOSTOFCOMPENSATION,OAMAGESASP O IDEDFOFiIN J SECTION3loeOFTHELABORCODE,INTEREST,ANDATTORNEV'SFEES. '� a[ AETENTION FEE: OCONSTRUCTION LENDING AGENCY PREALT FEE: � IHEREBYAFFlRMUNDERPF_NALTVOFPEFJUPVTHATTHEREISAWNSTRUCTIONLENDINGAGENCV FOR THE GERFORNANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUCO(SEC.3a9�,CIV.C.). - Z w ? LENOER'S NAME � F— LEN�ER'SADDRE55 w ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STATETNATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES J� � 1 AGREE TO COMVLV WITH ALL CITV AND CCVNTY OaDINANCE5AN0 STATE LA'NS RELATING TO BUILDINO � C NSTRUCTION,AND HLf7[BV AUTI ORIZE REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE Z AO -MENTIO�OIGROPER NSPECT PURPOSES. COMMENTS � _ —_ m ER ITTEE N (PR T ¢ py �� 6Z ____ _ _ � .__ __ _ � SIGN TURE R DATE = RECPT.NO. PAID BY VALIDATION ~ WHITE—D ment Copy,YELLOW—Finance Copy,PW K—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicanl's Copy �e a� �" �� '� �� "" {�� ° _ ..��°�a� . . y/ / �' � f;—��,.. . _ a ,� � � �:. �w��,�� - F � , ,�� _ _ U K=��, � � �� s � �..�� n�, � � , � �_, g ,.� _ a , g; � •_, i _ . . . . � : � � d1�„i� ,.,z „ � . .. �� .:, � — �� b , ,� . ., � • G � �� =t =�: _ � ,; 3 �� , � , '' � ,� � .. � �. � a M ,.w _ _ — CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION �Iw PRESS FIRMLY ADDRITE b APPLICATION J�] �J PERMIT J f, P/C ZI b, . Ur4eI r(r'I Ar•)9 1 A CNI I If/ # NUMBER APN L ISSUE c,T�7 TYPE OCC 0 TRACT ° 0 DATE(� (-CONST,GROUP OWNER ADDRESS ZONING SETBACKS CITY ZI TEL. r FRONT RW^ APPLICANT TEL. j REAR Fl SIDE/SIDE STREET RW^ CONTRACTO SIDE^ ADDRESS CITY ZIP4 13,YV TEL�I PROPOSED USE r Apt rw&C, ARCH/ENG/ I s;or,(n DESIGNER ADDRESS N0. DWEL. N0. N0. CITY ZIP TEL. STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION OWNER-BUILDER DECLARATION SFR/ADD/REM I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gard a/Ca Ort CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE:ANYCITYOR (n 9 COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC- LLI P 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 T w atio/Deck EP H ROVISIONS OF THE CONTRACTORS LI- CENSE LAW U- C P � HA 0 Pool/Spa TER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F 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 Z Re-Roof A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^I,AS OWNER OFfHE PROPERTY,OR MY EMPLOYEES WITH WAG ES AS THEIR SO LE COMPENSATION, Commercial WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUST- 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 CO 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 BUI D L OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS -f� TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- Valuation I U .ADJ AREA CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- QUANTITY DESCRIPTION TORS LICENSE LAW.). FEE ^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON Q U DATE OWNER H U LICENSED CONTRACTORS DECLARATION w W 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 Z MY LICENSE IS IN FULL FORCE AND EFFECT m b c�3c)iq �t r,or � LICENSE CLAS LIC N0. DATE Y CONTRACTOR WORKERS'COMPENSATION DECLARATION U I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: - z 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 U 40F THE WORK FOR WHICH THIS PERMIT IS ISSUED. w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION IS /^' 3700 OF THE LABOR C THE PERFORMANCE 0 THE WORK FOR WHICH THIS PERMIT IS 17 � r ISSUED. MV WORKERS P r t3AJJON INS C RIER AND POLICY NUMBER ARE: CONSTRUCTION �t CARRIER PLAN REVIEW POLICY NUMBER_:;1 LLW4L ELECTRIC AI (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS). PLUMBING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH HIS ERMIT IS ISSUED,I MECHANICAL SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS T ME S JECT TO THE WORKERS'COMPENSATION LAW LIFORNIA, ND AG EE AT IF I HOULD BE E INSPECTION FEE SUBJ CT TO HE WORKERS'COMP SA ON PRO ISION OF S TION 3 00 OF TH OR C 00 ISSUANCE F ORTHWITHCOMPL WIT TH SE R Is NS. �CO 1 DATE:APPLICAN SMIP WARNING: FAILURE TO SECURE WORKER'OMPENSATION COVERAGE IS UNLAWF ND SHALL BE ENERGY P/C SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUN E THOUSAND ENERGY PERMI DOLLARS($100,0(0),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS P 0 IDED FOR IN T SECTION 3708 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. RETENTION FEE: CONSTRUCTION LENDING AGENCY PRE-ALT FEE: I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANC OF T E HE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097,CIV. C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FEES 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING C NSTRUCTION,AND HEREBY AUT ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE AB-MENTIO ED PROPER NSPECT PURPOSES COMMENTS ER ITTEE N (PR T � Y 1, I SIGN TURE R DATE RECPT. N0. PAID BY VALIDATION 0 as 12 0 tL C) w 0 03 cc: 0 Q 0 0 Z LL 0 Q tZ a- W 0 U w CO CO ct C) ULj C) C) w C7 r� 0 C) w J J Ui 0 Q w Z w I- f Cr w d C) as m CO CO 1- WHITE-Deplmment Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy