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Home My WebLink About16679 (75)CITY OF DIAMOND BAR �'-- DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 PRESS "'- BUILDING PERMIT APPLICATION FIRMMMMMMMIY ADDRESS( �✓ APN LOT TRACT OWNER OXY ADDRESS r'"' CITY DjAmvcy f6k ZIP TEL. e -; ' APPLICANT 19).e, MO<d ,r L ai TEL9P CONTRACTOR 15 Y-r14LA-,1ALrf1P&J ADDRESS 'ice 4-3L§�,— 2_1� CITY !> {0"W A/I ZIP TEL7,2'� `; � 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 FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTYWHICH REOUIRESA PER IT TO CONSTRUCT,ALTER,IMPROVE,OEMOUSH,ORREPAIRANYSTRUC- TURE, PRIOR TO ITS ISSUANCE 50 REQUIRES THE APPLICANT FOR SUCH PERMIT i0 FILE A SIGNED STATEMENT THAT HE OR SHE IS IGENSEE PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U CENSE LAW (CHAPTER 9 (COMME CIN. WITH SECTION 70 0) OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR HE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTIO 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ❑ I, AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITHWAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE S`r iUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: HE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPRJVES 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 IRHOWEVER, THE BUILDING ORIMPROVEMENT IS SOLD WITHIN ONEYEAR 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 ALE).. n I, AS OWNER OF THE PROF ERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS L'. CENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROIIECTS' WITH A CONTRACTOP(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). 111 AM EXEMPT UNDER SEC.' B.8 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 DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSEE CLASS C .3 LIC. NO. DATE ="SS -0 l CONTRACTOR P® Cife'-, WORKERS COMPENSATION DECLARATION 1 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 DYSECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS WHICH IS ISSUED. I HAVE AND WILL MAINTAIr, WOR�IKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 9700 OF THE LABOR COD FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WDRKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (THIS SECTION NEED NDT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDREDDOLIARS ($100) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY AERSF IN ANY MANNER 50 AS TO BECOME SUSJECT TO THE WORKERS' COMPENSATION LA OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECTTO THE WORKERS' CO APENSATION PROVISIONS OF SECTION37000FTHE LABOR CODE. I SHALL FORTHWITHCOMPLY WITH THOSE PROVISIONS. DATE: APPLICANT. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS ISI W,OW), IN ADDITION TO THE COSTCF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION 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. $097, CIV. C.). LENDER'S NAME I LENDER'SADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHAT THEASOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING i CONSTRUCTION. AND HEREBY AUTHORIFE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. - 1 PERMITTEE NAME (PRINT) I URE OF PERMITTEE DATE APPLICATIONIf I PERMIT n P/C i DATE # NUMBERfflo-L ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE 11 PROPO GC E NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD(REM Garage/Carport WPatio/Deck LL PoQUSpa Z Re -Roof Commercial -- m aluation ''� Q ADJ.AREA QUANTITY DESCRIPTION FEE Q U U J W Z Z LD a Q U Z Q 2 W e CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICL _ - 7 J INSPECTIOTr FEE ISSUANCE J 1 9 2n ni SMTP ENERGY P/' I Y. ENERGY P - A ---"`-=-- RETENTION FEE: PRE -ALT FEE: TOTAL FEES 14(,o - COMMENTS RECPT NO. PAID BY VALIDATION '.,WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy �S,D F.& 2 �o 4 Ss' 'k, W ly, A� I 2'Y'. -EIA ."I A I "w" `137EE . . .... ..... ...... . --- - ---- --- EI-EC'TF�P�' E'ACII-J" L, Z� AID . . .... .. .. ---------- . . ....... . . ...... . ------ 3 ....... .. ... .... . ... ,, ... .... ... 31 ...... ...... PCIUSH HE L -A" - - --------- -- - . ...... . . ..... Vj .. . ... .... ------- L. tp P", t� P E J AS, A --- - ------ F'; 17�%7-q AlPi K"n . % �S,D F.&