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Home My WebLink About177870 O M J y W O CC 2 Z W 2 LLI f- R Cr3 Z On On Cn 2 F— CITY OF DIAMOND BAR Lk -�� DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive V (909) 860-3195 Fax (909) 861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY JOBSITE ADDRESS APN LOT TRACT OWNER��t.'%�jl(JC� ADDRESS�� CITY t: L ZIP STEL .� C APPLICANT TEL. CONTRACTOR qI: ADDRESS �+( CITY n c,r IPS 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 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 FIE CR 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 ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW) ): 111. AS OWNER OF THE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7(N44, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BN UILDS 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 OWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TOCONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOESNOT APPLY TO AN OWNER OF A PROPERTY WHO BL ILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECI-ION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE 15 IN FULL FORCE AND EFFECT n � LICENSE CLASS �_- LIC. NO. _3L' DATE CONTRACTOR Z WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I 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 RECUIRED BY SECTION 3700 OF THE LABORCODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIERANDAND POLICY NUMBER ARE CARRIER STi�3/CT �t9�1� POLICY NUMBER IX S �2 -3-C (THIS SECTION NEED INOTRE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS (E10D) 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, I SHALL FORTHWITH COMPLY WITH THOSEEOV S. DATE: � --A, e---APPLICANTWARNING: FAILURE TO SECURE WORKERS'COMPENSATIE IS UNLAWFUL AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (51 00,00(I), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 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. 3097, CIV. C.). LENDER'S NAME LENDER'S ADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE TO COMPLY WITI I ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HERE: BY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PP_URPOSES. ` C PERMIT EN (PRINT) SIG AT�RE QF PERM( EE DATE APPLICATION PERMIT 1// P/C r DATE ? � v, J /]�� NUMBER —L13 2 # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ _ PROPOSED USE, Q-XIIO lI LC%drgq c" d,,A ,` �✓ NO. DWEL. NO. VO. UNITS STORIES 3EDROOMS DESCRIPTION SQ, FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM U) Garage/Carport WPatio/Deck LL Pool/Spa Z Re -Root 0 Commercial In Valuation �""— ADJ.AREA QUANTITY DESCRIPTION FEE J Q U Ir H U W LU Z CD CL Q _U Z Q 2 U W CONSTRUCTION ;9. PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE {, I•J SMIP - ENERGY P/C 44_ - ENERGY PERMIT RETENTION FEE: l ' PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. PAID BY V VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION __Q —_ V PRESS FIRMLY JOBSITE — 3 —7----- -L./1 ADDRESS--/ T/ APN LOT TRACT OWNER ... Tlls "," l(Jr ADDRESS _5;" CITY " rcv'Y3"cy"-"' "'-L ZIP "5"!3 -TEL" C' - APPLICANT TEL. CONTRACTOR " aI ".J ADDRESS"" CITY n ["" IP L' " -TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT i AM E%EMPT FROM THE CONTRACTORS LI- CENSELAW 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 REPAIRANV STRUC- TURE, PRIOR TO ITS ISSUAIVCE, ALSO REQUIRES THE APPDCANT 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 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONSCODE) ORTHAT FIE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR 7HE ALLEGED EXEMP- TION. ANV VK)LATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).): ^ I, AS OWNER OF THE PROPERTY, OR MV EMPLOYEES W ITH 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 GODE: 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 W ITHIN ONE V EAR 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 CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70ad, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPI-V TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CANTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). ^ I AM EXEMPT UNDEFI 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 9 (COMMENCING WITH SECI-ION 7000) OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE, AND MV LICENSE IS IN FULL FORCE AND EFFECT. 3— LICENSE CLASS C LIC NO DATE CONTRACTOR Z WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PE:NALTV OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BV 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 BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MV WORKERS' COMPENSATIO}N-INdSUR—AjN-CE CARRIER^AND POLICY NUMBER APE: CT_ -_t9 --- CARRIER POLICY NUMBER —/.—' 3;/ 3 (THIS SECTION NEED IVOT BE COMRE7ED OF THE PERMR IS FOR ONE HUNDRED 00I1ARS (ElaoJ OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOI' ANV 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 C ODE,I S HA LL fO RFHWITN COMPLY WITH THOSEP OVISIONS. J/ ip DA7E: Lam_ PPLICAN7 _ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV AGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (f 100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTK)N 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. 3097, CI V. C.). LENDER'S NAME LENDER'S ADDRESS 1 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 CONSTRUCTION, AND HERE: BV AUTHORIZE REPRESENTATIVES OF TNIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURP OS ES PERMI E N (PRINT) SIGNAT RE QF PERMI EE DATE 0 0 0 0 w z 0 D Z 0 0 Z 0 Q 11 X w 0 U w v7 UD Q w Q J Z Q 0 w Z 0 w 7 LL J w 0 2 Z w 2 H w d C7 Z m U) 2 E- WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy 31 y/vZ 4—