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Home My WebLink About17387 (23)CITY OF DIAMOND BAR -- DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES I II 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 %v» BUILDING PERMIT APPLICATION JOBSITE ADDRESS/^ APN LOT TRACT OWNERP� /IA ADDRES CI ZIP TEL. APPLICANT TEL. t CONTRALTO. ADDRESS CI AFW24E TEL ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF CENSE LAW FOR THE FOLLOWING REASON (SEC 7031-5 BUSINESS AND PROFESSIONS CODE: ANY CITYOR COUNTYWHICH REOUIRESA PERMITTO CONSTRUCTALTER, IMPROVE, DEMOLISH, OR REPAIR ANYSTRUC- 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 (COMMENCINGWITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- ' FESSICNS CODE) ORTHAT HEORSHE ISEXEMPT 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 WITHWAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESSAND 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 HERSELFOR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDINGOR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). L IAM 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 ,(COMMENCING WITH SECTION 7000) OF DIVISIONS OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS_ LIC. NO. DATE,` ! C-rt)j 1_ CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED SY 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'OOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER ��J A POLICY NUMBER I (IHISSECRON NEED NOTRE MMPLETEDOF THE PERMIT IS FORONE 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 DF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT, 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 IS 100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN S ECTION3708 OFTHE LABOR CODE, INTEREST, ANDATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBYAFFIRM UNDER PENALTY OF PERJURYTHA'THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. CJ. LENDER'S NAME LENDER'S ADDRESS i, (CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE 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 PROPEflTY F R INSPECTION PURPOSES. i I PERMITTEE NAME (P TI I SIGNATURE OF PERMITTE DA - a� PRESS FIRM APPLICATION I `5 C ` PERMIT P/C 1"13 i DATE Y i NUMBER _� # ISSUE y TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPO_Us is 401; 724 NO, DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA VALUATION SFR/ADD/REM Fn Garage/Carport W Patic/Deck U- Paol/Spa 0 Z Re -Roof 0 Commercial - 5 M Valuation _. ADJ.AREA QUANTITY DESCRIPTION FEE J U H U w W U Z_ m d J U z 2 U W 5� CONSTRUCTION . PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP %0 ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy M SOT!7- K F I - --- — ----- . AMNIal . ......... LERA 6A 1 WATA WHY —u'E DE-3, A WHAT; E, F, Fi ON 32 E UK, Lim-milii? ------- loll MMSM I±MAL Al "I"I'll-I'sy. - SOT!7- K F