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Home My WebLink About17675 -,1�,.�` � CITY OF DIAMOND BAR \,�"" � � - ��`` DEPARTMENT OF COMIvfUNITY&DEVELOPMENT SERVICES � 21825 E.Copley Drive �—�J > (909)860-3195 Fa�c(909)861-3117 �' PRESS \%.�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE 1 bl � � (� �` APPLICATION � / � � � PERMIT P/C o ADDRESS I 0��i'9M1'� J�" Dj�� ,✓�'`� DATE � NUMBER. # � ISSUE TYPE OCC APN LOT TRACT DATE �� CONST. GROUP � OWNER � O —�+ o ADDRESS 1"V ZONING SETBACKS Z CITY I�1/�{�"' ZI � �' TEL. FRONT RW__ � oAPPLICANT TEL. REAR ❑ SIDE/SIDE STREET__ RW__ ❑ ¢ CONTRACTRR� _ SIDE _ ❑ � ADDRESS.rU h ) � � CITY�� ZI TEL. PROPOSED USE O � w ARCH/ENG/ • wDESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cn � OWNER-BUILDER DECLARATION SFRJAD�/REM O � I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAi I AM EXEMPT FROM THE CANTRACTORS LI� G8f898/CBfPOR W CENSEIAWFORTHEFOLLOM/INGREASON(SEC.�031.56USMESSANDPROFESSIdJSCADE:HNYCITYOR (n U COUNTYWHICHREQUIRESAPERMITTOCONSRUGT,ALTER,IMPROVE,DEMOLISH,OHREPAIRANYSTRUG W Patio/Deck Z TURE.PRqR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNE� W w STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE UW(CHAPTER 9(CUMMENCING WITH SECTION 7000)OF DIYISION 3 OF THE BUSINE55 AND PRO- u" POOVSPe O FESSIONSCODE)ORTHATHEORSHEISEXEMCTTHEREFROMANDTHEBASISFORTHEALLEGE�EXEMP- (� U TION.ANVVIOLATIONOFSECTION7031.58VANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � A CIVII PENALTV OF NOT MORE THAN FNE HUNDRED DOLWRS(f500).�: , Q ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, Q CORIRIBfCl81 Z YVILI DO THE WORK,AND TME STRUCTURE IS NOT INTENDED OR OFFEtiED FOR SALE(SEC.7o6a,BUSI� J NESS AN�PFOFESSIONS COOE:THE CONTRACTORS LIGENSE LAW DOES NOT APPLY TO AN OWNER OF � PHOPERTVWH08UILDSORIMPROYESTNEREON,ANDVlHOOOESSUCHWORKMIMSELFORMEFSELFOR m , CL THFiOUGHHI50HHEROWNEMPIOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAFENOTINTENOE�OH W OFFEREDFORSALE.IF.HOWEVER,THEBUILOINGOR'.MPROVEMENTISSOL�WITHINONEVEAROFCOMPLE� � TION,THE OWNER-BUILDER WILL HAVE THE BUflDEN OF PROVWG THAT HE OR SHE DID NOT 6UILD OR Z IMPROVE FOR THE PUHPOSE OF SALE). � ❑I,ASOWNEROFTHEPROPEFTV,AMEXCLUSIVELYCONTRACTINGWITHUCENSEDCONTRACTORS Q TO CANSTRUC7 THE PROJECT(SEC.]oa6,BUSINESS AND PROfESSIONS CODE:THE CONTRACTORS LI- V2Ill2IlOf1 ADJAHEA W GENSELAWDOESNOiAPPI.YTOANOWNEROFAPROPERTVWHOBU1LD50RIMPROVESTHEFEON,AND = WMOGONTRAGTSFORSUGHVROJECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE ~ TOFSLIGENSELAW.). Y J � �I AM EXEMPT UNDEFI SEC. e.&F.C.FOR THIS REASON Q � U � V' DRTE OWNEfi U �Q LICENSED CONTRACTORS DECLARATION w CC I HEREBYAFFIRM UNDER PI:NALTV OF PERJURY THAT I AM LICENSED JNDER PROVISIONS OF CHAPTER � d 9(COMMENCING WITH SEC110N 7000�OF DIVISION J OFTHE 6USINESS AND PR0'rE5510NS CODE,AN� Z X MV LICENSE IS IN FULL FORCE AND EFFECT m � LICENSE CLASS ��I.1y�C.NO. V j J V pq7E 0-�- lt,.s... CONTRACTOR � W � WOFIKERS'COMPENSATION DECLAFiATION J a � I HEREBY AFFIRM UNDEti PI=NALTV OF PERJURY ONE OFTHE FOLLOWING�ECLAPATIONS: U � Z Q � IHAVEANDWILLMI\INTAINACERTIFICATEOFCONSENTTOSELF-INSl1REFORWORKERS' S COMPENSATION,ASPROVIDEDBYSEC710N]�DOOFTHEIABORCODE,FORTHEPEFFORMANCE U Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSVED. � O _/j w 'Y I HAVEAN�WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION `1 ^ � . r Q �3]OOOF HE LABOR CODE,FOR THE PEPPoRMANCE OF THE WORK FOR WHICHTHIS PERMIT IS � J� _ ISSUED.MY WORKIE/RS'�'CQ�MP,,E SATION IN{SURANC_E,C.q,.`RRIER AND POLICV NUMBER ARE: CONSTRUCTION __.,_,_,_.._..____. w � � GARRIER �"C V�� t'l N�lJ' - PLAN REVIEW � POLICY NUMBER_ �� QY �� 1' ELECTRIC Z � Q � (iHISSECi%NJNEmNOTBEOJMPLETEDOFI}1EPERMITIS�ORONEHUNDREDDOl1.AA5(510D10RLESS). PLUMBING W 1 CERTIFV TfIAT IN'fHE PERfORMANCE OF THE WORK FOR WHICH THIS GERAAIT IS ISSUED,1 MECHANIGAL Z (,'} SHALLNOT EMPLOV ANV PERSON INANV MANNER SO AS T08ECOME SUBJECT TOTHE � WORKERS'COMPENSATIONLAWSOFCAUFORNIA,ANOAGREETI{ATIFISHOULDBECOME INSPECTIONFEE SU&1ECT TO THE VIORKERS'COMPENSFTION PROVISIONS OF SECTION 3]00 OF THE L480R � COD ISHALLFOFITHWITHCOMPLVWITHTHO PR� % �SSUANCE = O j� 0 DATE: ��- APPLICANT -.�r`-��r __ SM�P r��/ w ' ENERGY P/C J WARNING:FAIIURE TOSEGURE WORKERS'COMPENSATION COVERAGE IS 11NUWFUL,ANO SHALL BE � SUBJECTANEMPLOYERTOCRIMINNLPENALTIESANDqVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS(5100.000�,IN ADDITION TOTHE COST OF CDMPENShTION,DAMAGES AS PROVI�ED FOR IN � � SECTION 3�oe0:THE LABOq CODE,INTEREST,AN�ATfORNEV'S FEES. RETENTION FEE' � � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UN�ER PENALTY OF PERJUflY THAT THEftE IS ACONSTRUCTION LENDING AGENCY a- FOR THE PERFOFMANCE OF iHE WOPK FOR WHICH TH15 PERMIT IS ISSUE�(SEC.309],CIV.C.�. Z w S LENDER'SNFME � F- LEN�ER'SADDRESS y ¢ I CEfiTIFV THAT I HAYE ftEi1D THISAPPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FEES � ' � w I AGFiEE T�GOMPLV WITM ALl qTY AN�COUNTY ORDINANCES AND STATE IAWS RELATING TO BUIL�ING � CONSTRUCTION,AND HER EBY AU I HORRE REPPESENTATIVES OF TMIS GOUNTV TO ENTER UPON THE zABOVE-MENTIONED PROPEHTV FOR INSPECTION PVRPo5E5. COMMENTS - � �� PERMITTEE NAME IPflINT� � �y-�r,-��-�� .�('�l0�- _ � SIGNATUREOFPERM�T� �L' DATE FIECPT.NO. PAID BY VALIDATION _ -- ~' WHITE—DepartmeM Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy.GREEN—ADPlicanPs Copy � i i ; �&�n� �r��d , . . �'� ; - ";4, ''' _ _ i��' i�.r�.. „ ��3��%�: . - � , . . . �lw�.��.n ix+�'�. �JL�GZ �.� _ � � _ e. � � � �� .d . w, ��. n. . fi �� . ��P�� '; �r>�� , ��.. �� a��r�, ''�1� c � _ h �"�.�'�"� r,� smm � : �: � � �� ; di' i . .. . .. . ..... .. . . . . ... _...... ' , . 5 .._ _. . . . _.... � � �i 1 �"yq ' Ri6� �� .;��g 1 �" � . .. .. .. . .. . . . .... . .. .... .... . . .. . .. ��. F4�✓ ��e:Ayu,• �' ��d�q�.,., _ � � � - i ,:. ... .. . .. ' m �... `�L :` . .... .. . . . . .. .. ... .. . ..... ... .... . ..... ... . o � -d �.'.p a� �" '.. � �� .�' i ° �'� `� 5', . .... . .. . .. .. .. . . . ._ . .. ... ... ._ ...... . .. .. .,a��.� . �a��;�ai�r .. ., _. .. CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES V 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBTE ADDRESS i V J L-CNuW�6n fir'Dec'I3v��-- APN LOT TRACT OWNER A ADDRESS PO CITY ZI I t'TEL APPLICANT TEL. CONTRACT R cc ADDRESS Lfl CITY(ZI TEL. 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 REQUIRESA 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 U. 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- TK)N.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($500).): ^ 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 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 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 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 ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). U T AM EXEMPT UNDEFI SEC. B.&P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HERE BY 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 FORCE AND EFFECT. //-1 ck� 0 � � U.IC. N0. LICENSEE CLASS DATE 0-2-CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: -1 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 ISSUED. MY WORKERS'SATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER /^' POLICY NUMBER_. (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IB FOR ONE HUNDRED 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 SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR COD I SHALL FOFITHWITH COMPLY WITH THO PROVISIONS. !c DATE:APPLICANT. J 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($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN J SECTION 3708 OF THE LABOR CODE,INTEREST,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.). J - LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE CONSTRUCTION ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. A PERMITTEE NAME(PRINT) p/ I DATE SIGNATURE OF PERMI----'�� C ERMIT) r. 7 5 P/C APPLICATION ID 7-P DATE( N -) # UMBER(yy/ ISSUE TYPE ' OCC DATE CONST. GROUP ZONING SETBAC KS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ PROPOSED USE 0 I N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION S0. FT FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM W Garage/Carport W Patio/Deck LJ Pool/Spa 0 Z Re-Roof 0 Commercial 5 LYI Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U W LU W 0 a U W 'T /7/0 CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP y ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES I f COMMENTS RECPT. N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Uopy,ULJLUtNHULt-rile Uopy,OnttN /16Jv