HomeMy WebLinkAbout17673 �
CITY OF DLAMOND BAR �__������(;�
�'�� __, I}EPAR"I'MENT O�'COMMUNTfY&DBVELOFMENT SERVICES
� 21&25 E.Copley Drive ^��
(909)860-3195 Fax(9Q9}861-3117 �_�� PRESS
'`%»��' BUILDING PERMIT APPLICATI(}N FiRMLY
� JOBSITE y��2p j rtl �,,,�j�r�j'�r �} APPL�CATION ,�� PERMIT P/C
a ADpRESS.__U �(iVl ( �F�� Y(���• DATE �� NUMBER � #
� ISSUE �� TYPE OCC
APtv������ T TRACT _ DATE " CONST. GRflUP
� OWNER � _ _
� ADDRESS ZONING SETBAGKS
� GlTY Ut{�" ZI �'�L�[�', – FRON7 RW f_l
APPLICANT .^ TEL.__ REAR O
z SIDEtSiDE STfiEET RW i�
� CONTRACT R � _ SIDE ❑ �
q� ADDRES �{ � PROPOSED USE b`! � )
� CITY,p��__ ZI�� TEL�.���=�.�
w ARCH/ENG/
� DESIGNER_ _ NO.DWEL. NO. O.
� ADORESS UNITS STORIES BEDROCIMS
= CtTY ZIP TEL.
� — DESGRIPTIORF S{}.FT. FACTOR PSF AQJ.AREAIVALUATICIN
v�
� OWNER-BUILDER DECLARATION SFRlA�D/AEM
O
p I HEREBY AFFIHM UNDER PETlALiY OF PERJUpV THAT I AM EXEMpT FROM THE CON7RACTORS LI� � Garage/Carpon
W CENSELAWFORTHEFOLU�WINGREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:AI:VCITYOR
� COtR1iYWHICHRE9UIRESAPERMITTOC�NSTRUCT,A�TER,iMpR6VE,DE610l�SN,OflREPAlRANYSTftUC- {jJ patIOJDBCk
w TURE,PRIOR TO 17S ISSUANCE,AL50 REQI11RE5 THE ApPLICANT FOR SUCFI PERMIT TO FILE A SIGNED W
.� STATEMENT THAT NE�R SHE IS LICENSE�PUqSUANT TO 7ME FlROVISIONS QF TNE fANTAACTQRS li-
� CENSE lAW(CHAPTEP e(CAMMENdNG WiiH SECTION I400}OF DNIS�ON 3 OF THE BUSME55 AND PRC7� � �OOIISPB
FESSIONSCODE)4RTHATHEORSHEISEX[MPTTHEREfHOMAN�THEBA515FOR7NEALLEGEDE7(EMN� (�}
� TION,ANYVIOL0.TIQNQFSECTION7a3t.58YANYAPPi1GANTFORRGEPM175U&IECiS7NEAPPUCANT70 Z Ae-Root
� A CIVIL PENALT'/OF NO7 MORE THAN FIVE HUNDRED DOLUiRS(SSDO�.):
� ❑I,ASOWNEflOFTHI:PROREFT'Y,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION. � COfnmetCiel
WtEI OQ THE W{7RK,AND i HE STRGCTURE IS NOT INTENDED Ofl OFFERED FOfl SAIE{SEC.7o4e,BUSI-
NE55 AND PROFESSIONS CODE:THE CONTRACTONS LICENSE LAW DOES NOT APPI..Y To AN aWNER OF
� PROPEflNWHOBUIL�50RIMPROVESTHEPEON.A�DYN10UnE5SUCHWORKHIMSELFORHERSELFafl m
('[ TFIRQUGMHISORHEROWNEMP�OYEE9.PROV�6£6Th'ATSllCNiMPROVEMENTSARENOTtNTENpEDOR
� OFFEREDFORSALEIF,HOWFVER,THEEUILDWGONIMPROVEMENTISSQLDW'THINONEYEAROFCQMPIE�
� TION,THE CIWNER•6UIlpER WfLL HAVE T4�.E BUR�EN Of f"ROYING TI�IAT HE Ofl SN£DID NQT BU7L4 Oft
= IMPROVEFORTHEPt1RPOSEOFSAIEj.
U I,AS ONMER OF iHE PPbPERTY.AM EXCLUSIVELY CONTPAGTING W17H LICENSEO CONTRACTOF$
� T4 CONSTRUGT TNE PROJECT(SEc,7oab,9U51NES5 AND PROFESSIONS COpE:THE CDNTRACTQRS t}. V3�UHtiOt1 AOJ.AREA
L1] CENSEIAWDOESNOTAPPLYTOANOWNEFOfAPROPERTVWHOBUIL�SOpIMPflCJVESTHEREqN.ANp
� WMOWNTqPCTSFORSUGHPROJECTSWITNACON7RACIOR(5)LICENSEDPURSUANTTOTHECONTRAC� QUANTITY QESCRIPTION FEE
Y TORSUCENSEtAW.}.
� J
� CIAMEXEMPTUNDERSEC. ,,,, @.BPGFOflTHISREASIX^I Q
� _ [L
� DA7E ._OWNER.._.. _.__.._._ U
W
Q �IGENSED GONTRACT4RS DEGLAftRTiON �j
� IMEREBYAFFIPMUNDERPENALTVOFPERJUftYTHATIAMLICENSE�UNDERPROVISIONSOKCNAPTEF �.
[L 9{CARIMENC�WtTri SEC(IDN 760a}OF 6IVISIQN 3 dF THE BUS�N'cSS AND PRQFESSiONS COOE,AND Z
w MV LICENSE IS IN K61LL FORCE AND EFFECT. m
Q LICENSE CLASS������NO. .��1��}E�yi�'�>—..� �
„A�"�'
� DATE_�r�.�� COtd7ftACTpR,�,,,.�.�.,h�-• a
W
t� Wi?RKERS'C6MPENSAT}ON DECLRftATfON �
a
� U
� I HEREBY AFFIRM UNDEA PL=NALTY OF PERJURY ONE OF TNE FOILOWING 9ECLARATIONS: Z
Q
� I HAVE ANp WILL MNINTAIN A CER7IFICATE tlF GONSENI TO SELF-INSl1NE FqR WORNEPS' _
Z �cAMPENSAT�N,A5 PRpViDED BY SEGTION z7q00F 7HE U80R C6pE,FOR THE PERFQfttaANCE C�
d OFTHE WORK FOR WHICN THIS PERMIT IS ISSUEp. �
C> .
� i HAVE ANp WILL Mh�NTAiN WORKERS'COMPENSATION INSURANCE.A5 RE6UIRED 8Y SECTION .�''}
� �3]COOF 7HE LA80F',CODE,FOR THE PEflF4RMArvGE OF THE WqFK fpH WHICHTHIS PERMIT IS ��. �iJ
_ ISSVEO.MY W6FiKERS"c;OMP"' ATI N INSURAt+iCE CAftRiE AND POt:CY NUMBERARE: CONSTF3UGTICSN � �,_._
� caRaiEa � •�'/��'y ....� PLAN REVIEW ..
� POLICYNUMBER_ �)„t�' --- ELECTRIC _.,, ...—....
d
� (MiSSECTqtJNEEb!JOTBE�APLEfEDOFTHEi'E�ISiORONEHUMREDDOI.LAiiS(51WiORLESSj. PLUMBING _ ..—, .—
w I CERTIFY THAT{N THE PERFOFtMANCE OF iNE WOftK FOR WNICHTNiS PERMiT'.S ISSUED,I MECHANICA� .
� _____" _
(,'3 SMALL NO�EMPI.D`'ANY PERSON IIJ ANV MANNER SOAS TO 9ECOME SUBJECT TO THE INSPECTION FEE
� WORKEPS'COMPENSATIONLAWSOFCAUfORNIA,ANDAGREETHATIFISH�ULDBECORIE —�-rs—„
SU9JECTTO THE W6RKER5'C6MPENSATION PROV15KKdS OF SECTItSN a7bo{�F 7HE tA8+7R �,t,�Va, T�-
� CODE./t�SNALLFC/RfHWITHCOMPIYWITH EPROVISIONS. ISSUANCE ,.,,__,
� j �ra .�A....�.�.�. SMIP _ ________��--
� OATE;�'i�_���.((,�;6.,rM1PPL�CANT , ' `
w ENEf4GY P!C _ ... .
� WARNMG:FAiIVRE TO SECURE WORKERS'COAiPENSATK}N COVERAGE IS VNtAWFUt.AND SHAIleE "—
� SU&IECTANEMPL4YER10CRIMINALPENAL'fIESAN�CINLFINE5UPT00NEHl1NDFE�TNOUSANO ENERGYPERMIT _,.�„
OOLLARS(51 W.fl001.IN AODITION TO SHE COST OF COMPENSATIqN.�AMAGEg AS 7ROVIDE9 FOfI IN "—T•c"""i
� SECTION 3T06 OF THE LA80R COOE,INTEREST.ANO ATTOFiNENS FEES. RETENTION FEE: __. �✓
d CONSTRUCTION lENOING AGENCY PRE-AlT FEE: . . -
O
� IHEREBYAFFIqMUNDEfIPF_NALTYOFPERJURYTHATTNEFIEISACONSTRUCTIQNLENOINC:AGENCY ___ __,,,.
a- FOR THE PEftFOFMANCE OI-THG WDftK FOft WHICN THIS FEAM:T IS ISuUED t5EC.309r,GIV.C}. -
.Z _
W
� iENDER'SNAME __,_, .._. . .._-....._.
� �ENCSFR'SAODRESS�_,,,,._ . ��- r/� /� (\ )
� ICEflTIfYTMATIHAVEREADTHISA�PUCATIQNANpSTATETHATTHEA60VEINFORMATION�SCORREC7 1 VT/'1L�E�S �+
�li i AGREE TO C:OhiPi.Y WITN A�t GtTY ANb COUNTY OPDINANCE�dND STATE lAWS RE�ATFNC TO Rt11l0ING
� CONSTRUCTION,AND HEREI3V AUTHORIZE REPRESENTATIVES OFTNI&COUN7vT0 ENTEF UPON THE
� A90VE-MENTIONEOPROPERTYF�RlN5PEGT���NPlIRA05[S- {�'QMMENTS
._ ♦ .. . ....__..
d
J �1�j].
� t�---=�`='�.��- '-_
� SEfl EENQAP(PRINTI �� `^`y�T�����
- —_ —
=7�� !
�
RECP� PAICt SY -�s�� � VA�-==Z•�
WHITE-Depanment Gopy,YELLOW-Finance Copy,PMK-Assessor Copy.GOLDENFOQ-File Copy,GREEN-Applicant's Copy
� �, ...2��N,17,u,�
��`w'�_ , "�`����,�. �V q � J ���.
. < _ . . . . � . ... ._ _..... . .. _ :.
,�j�L��'6'� .�`'Z�.. _
� _ _ �_ ' :'�� ,�������'��� _
; � _ _ �
; _
� ;
� _,F c.� �
� � � � ; �� - _
•. � � � �,��:�� �� :, _ _ _
�. h �� �� ��P��,��� � ��
..zl.. d r`:� � .i� I��'E "Ts���. ._.. . .. .._ _.. .. . .. .. . _ ... . . ._.
i : ... .. . ... .. .... . .. .. .. . ...
y � P �
.,:�� � n.,aN� M ��"��'j''C.�.a Y, ��.... ... ... .. .. ... ..
. ' � -P "Ai`°.:'� k , :. .. ._.. . ... . . . . . . .. ._ ._ ... ... ..
��i � ,
:" ° � ��:J s� . . _.. . _.. ._
� .. .... .. ... .. ...... . .— .
rc = ^ . ... ... .. . .... . .. _ . . .. .
SI
�3�
_ ;l � „e ,. �. �:
„ �.. � .'�, d y L$ . .... . .._. ..... .. .. ...
_ ���. ; 5., f` 3 y^ . r ..— .. ..... . . ... . .. . _ .�...._ .e... ..._. ._,... — —
II
elclffl_r
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3 117
BUILDING PERMIT APPLICATION
�mtx
PRESS
FIRMLY
JOBSITE
16�b
ADDRESS>
gau#'4�/pr o.
AP L T TRACT
OWNER
ADDRESS jun 14 g"
CITY DXp,_lickr-ZI TEL.
APPLICANT_TEL.
CONTRACT R
ADDRES .VO
CITY ZlOjjjW 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 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 B (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($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 TI-PT 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. &PC, 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 FORCE AND EFFECT.
LICENSE CLASS I(C. N0.
DATE 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 SECTlON
3700 OF THE LABOF: CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUEE. MY WORKE RSQNURANC-E CARPIE
AND POLICY NUMBER ARE:
I
G
CARRIER
}
r
� � , �
POLICY NUMBER
(THIS SECTlON NEED IJDT BE COMPLETED OFTHE PERMIT IS 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
CODE,SHALL FORTHWITH COMPLY WITH E PROVISIONS.
DAT
��g M)APPLI
T
CAN
E:
WARNING: FAILURE TO SECIJRE 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
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.).
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
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
(Sko ea
E:AIPRINTI
Z
E 0 P DATE
APPLICATION 61 � PERMIT/C
DATE NUMBER #
ISSUE 6/) TYPE OCC
DATE � CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE 6
N0. DWEL. N0. 0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFRJADD/REM
U) Garage/Carport
LU Patio/Deck
LL Pool/Spa
0 Re-Roof
Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
I-
U
W
W
0
z
m
0
Q
U
Z
2
U
LLI
7. -2,b
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: /
PRE-ALT FEE:
TOTAL FEES -V
COMMENTS
"71
VALIDATION
7t� RECPT N0. PAID BY
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
J��L c�'6'Z