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Home My WebLink About15008 (19)1 CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICA ii JOBSITE ADDRESS 1x APN_ LOT TRACT j _ OWNER 4"'Xii,y:, ADDRESS CITY ZIP TEL APPLICANT C !LUL- — �iF(�•.✓iI F� TEL. CONTRACTOR_ O CITY L ARCH/ENG/ L DESIGNER A1 y ADDRESS CITY ZIP TEL. n n i OWNER -BUILDER DECLARATION 7 1 HEREBY AFRRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS L6 1J CENSE LAW FOR THE FOLLOWING REASON (SEC.7031.6 SUSINESS AND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT. ALTER, IMPROVE, DEMOLISH, ORREPAIR ANY STRUC- !.1 TUBE. 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' C CENSE LAW (CHAPTERS (COMMENCING WITH SECTION 7000) OF DIVISION a OF THE BUSINESS AND PRO-FESSIONS CODE)ORTHAT HE OR SHE IS EXEMPT THEREFROMAND THE BASIS FOR THE ALLEGED EXEMP. TION.ANY VIOLATION OF SECTION 7031.68Y ANYAPPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 0I, AS OWNEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIRSOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS HOT 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 L THROUGH HIS OR HEROWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR 'LjOFFERED FORSALE.IF,HOWEVERTHEBUILDINGORIMPROVEMENT1550LDWITHINONEYEAROFCOMPLE- Z TION, THE OWNER -BUILDER WILL HAVE THE BUHUEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE I. y� ❑1, AS OWNER ORTHEPROPERTY,AMEXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS i TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U. L CENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTY WHO BUILDS On IMPROVES THEREON, AND L WHOCONTRACTS FORSUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTOTHECONTRAC- TORS LICENSE LAW.). O IAM EXEMPT UNDER SEC. B.3 P.C. FOR THIS REASON DATE OWNER --- —.. _ LICENSED CONTRACTORS DECLARATION HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER L 0(COMMENCING WITH SECTION 7000) OF DIVISION 30F THE BUSINESS AND PROFESSIONS CCDE,AND �G MY LICENSE IS IN FULL FORCE AND EFFECT. �^ LICENSE C1. LIC. NO..,,.E_p-yam. `y DATE—_.�9 "✓�. _ CONTRACTOR JLI r' n WORKERS'COMPENSATION DECLARATION IHEREB FIRM UNDER PENALTY OF PERJURY ONE (IF THE FOLLOWING DEC LA 10 E AND WILL MAINTAIN ACERTIFICA7E OF CONSENTTO SELF -INS EFORWORKE S' COMPENSATION, AS PROVIDED BY SECTION 3700 of THE LABOR CO , FOR THE PERFORMANCE HE WORK FOR WHICH THIS PERMIT IS ISSUED. iHAVE AND WI LL MAINTAIN WORKERS'COMPENSATION INSURANCE, SREOUIRED BY SECTIOlI_..: ' 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK F _PERMIT IS ISSUED. MY W'ORKF S' PENSATIIOLN INSURANCE CARRIER AND PCLICY NUMBER ARE: '` � CARRIER POLICY NUMBER_1,Mt (IHSSELRION NE®NDTBE WNIPLETEDOF7HE PEM7rT6 FOR ONE HUNDRED DOL (S1OD)ORL } Jul z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is SUED,I Lu SHALL NOT EMPLOY ANY PERSON IN ANY MANNER BOAS TO BECOME SUBJECT TO E ;q WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BEC SUBJECT TO THE WORKEflS'COMPENSATION PROVISIONS OF SECTION 3700 OFT E LARD D CODE, I SHALL FORTHWITH COMPLY WITH TH PROyIGInuA 7 s� —F__ p DATE: T Ci APPLICANT. _ G` ._.. I _ _m, J WARNING: FAILURE TO5ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SE Ly SUBJECTAN EMPLOYERTO CRIMINAL PENALTIESAND CIVILFINES UPTOONE HUNDRFO THOUSAND DOLLARS (5I 00,ODO), IN ADDITION TO THE COST OF COMPENSATION. OAMAGE.7 AS PROVIDED FOR IN J SECTION 3708 OF THE LABOR CODE, INTEREST, ANDATTORNEY'S FEES. OCONSTRUCTION LENDING AGENCY � I HEREBY AFFIRM UNDER PENALTY OF PERJURY THATTHERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3057, CIV C.). Z LU ELENDER'S NAME LENDER'S ADDRESS F-- LU I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE ABOVE INFORMATION ECT. 'COUNTY CL TO BUIL ORDINANCES AND STATE. LAWS RELATING TO BUILDING I0.GREE TO COMPLY WITH ALL CITY ANDES AND 0CONSTRUCTION, AND HEREBY AU THORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE Z ABOVE-MENTIONED PROPERTY FORJUSPECTION PURPOSES. m PERE INT) on / on SIGNAT F PERMITTEE -- DATE TION PRESS FIRMLY APPLICATION PERMIT 1P/C DATE NUMBER `� V# ISSUE TYPE OCC DATE_ CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR U _ SIDE/SIDE STREET RW 17 SIDE PROPOSED USE car Zi V r NO. DWEL. oo. / NOQC. UNITS STORIES _ BE DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM Garaga/Carport W Patio/Deck LL PooVSpa Z Re -Roof � 0 Commercial m ValuationA` ADJ-AREA QUANTITY DESCRIPTION FEE a �`�� u •�'� E' X i r� U W I Z_ 2 �ON&R'ST11CTRC V ll P UMBI�JG1 C YYMSSAAANNNfff!l/CAL' NJ CTION FEEtf�+'+:' _ ISSUANCE 't SMTP ---'---------..,_.— ENERGY P/C ?•" ENERGY PERMITRETENTION FEE: .LG'yVrl ;� a .. �• ` PRE -ALT FEE:, I'•" ` TOTAL FEES , COMMENTS-- - RECPT NO. PAID BY _. VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applirant's Copy