The URL can be used to link to this page

Home My WebLink About14912 (15)LLS 1 h� LLJ C3 InL 5 fn cn L= O 8 �o Z W illi F CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Dive Suite 190 (909)860-3195 Fax(909)961-3117 BUILDING PERMIT APPLICATIONJOBSITE __ 1 ADDRESS �)j� TIO APN LOTS_ TRACT OWNER ADDRESS CITY ZIP TEL APPLICANT f�E r��/T/it// TEL ,� CONTRACT R WK ADDRESS L CITY eH/A/U H/G C_S ZIP TEL ARCF1/ENG1 DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I MI EXEMPT FROM THE CONTRACTORS T. . CENSE LAW FORTHIFFOLLOWING REASON (SEG 7071.5 BUSINESS AND PROFESSIONS CODE ANY CITYOR C0LHTYWHtCH RE -O f SAPERLTT0 C0NSTR=.ALTER IMPROVE, DEMOUSH,OR REPAIRANYSTRUC• TURF PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE 6 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE UW (CHAPTER 5 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRD• FESSDNS CODE) OR THAT HE OR SHE IS EXEMPT THEREFRCIA AND THE BASIS FOR THE ALLEGED EXEMP• TION.AW VIOLATION OF SECTION 7071.5 BY ANYAPPLHCANT FORA PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS tFSODL): U LASOWNER OF THE PROPEFITY.OR MY EMPLOYEES WITHWAGES AS THEIR SOLE COMPENSATION. WILL 00 THE WORK AND THE STRUCTURE 6 NOT INTENDED OR OFFERED FOR SALE (SEG 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 HE RSELF OR THROUGH HIS OR MER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR CFFERED FOR SALE IF, HOWE'VERTHE BUILOINGOR IMPROVEMENT IS SOLD WfTMN ONE YEAROFOOMPLE. TION, THE 0WHERWILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DD NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} O LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH UCENSED CONTRACTORS TO CONSTRUCT THE PHO.IECT (SEC, 70". BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE UW DOES NOT APPLYTO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WIgC0NiRA(0T9 FOR SLK]I PR0JECr3 WITH ACOTRACTOR(S)LKOENSED PURSUAMTOTHECONTRA(} TORS UCENSE LAW} O IAM EXEMPTUNDER SEC. - B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 91C0MMENCNG WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS NO PROFESSIONS CODE, AND W LICENSE IS N FULL FORCE AD EFFECT. EAA LICENS 5 �/..{�� LIC. NC. O DATE '0 CONTRACTOR A. COW TIAJI WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF TME FOLLOWING DECLARATIONS: I NAVE AND W LLMAJ_ A CERTIFICATE OF CONSENT TO SELFANSURE FOR YORKERS' OOMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WLLMANTNN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION 57000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CARRIER POLICYNMBER (TMSECTION NEED NOT BE CCNfU7EDCFTHE PERMIT 6 FOR ONE H UNDREDDOl1AT6 Mi W) ORILESSS 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR YMICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SLXUECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WI K75E PROVISIONS. DATE: 9-5-00 APPLICANT. j� WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWRUL, AND SHALL SE SUBJECT AN EMPLOYER TO CRMINAL PENALTIES AND CML FINES UP TO ONE HUNDREDTHOUSAND DOLLARS (SIOO,000), N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FORIN SECTION 3700 OF THE LABOR CODE. INTEREST, ANDATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBYAFFIRM TINDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED (SEG 3097, CN. C.), LENDERS NAME LENDER'SADDRESS I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I ADPEE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING IO CONSTRUCTN, AND HEREBY HO AUTRIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENT10NED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE NAME (PRINT) SIGNATURE OF PERMITTEE DATE 01 PRESS FIRMLY `O I y9i IC —) 0 DATEICATION NERIVIIT UMB R ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDESTREET RW ❑ SIDE 0— P . ROPOSED PROPOSED USE ( TTIAC ejamn ooep_ NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport W PatiolDeck LL PooVSpa Z: Re -Roof C3 Commercial m Valuation QQ ADJ.AREA OUANi DESCRIPTION FEE U H U W J W L'} Z m J a a U z a U D CONSTRUCTION PLAN REVIEW l� ELECTRIC i PLUMBING- ' MECHANICAL INSPECTION FEE ot,U ISSUANCE c. C% SMIP "Chi 1 . ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE - EV-_ V; TOTAL FEES 3 COMM� RECPT. NO. PADDY VALIDATION WHITE—Department Copy, YELLOW—Finenea Copy, PINK—A6sewor C0W GOLDENROD—File Copy, GREEN --Applicant's Copy