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Home My WebLink About15077Y0• CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 %9 BUILDING PERMIT APPLICATION JOBSITE / �, ,�T ADDRESS 2 � 7 � � Z �11Tra0e APN LOT TRACT OWNER 5ARL S ADDRESS Z 3787 11L CITY %ANQI%d d4AZIP TEL. APPLICANT TEL. CONTRACTOR _ ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP _ TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI. CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONSCODE: ANYCITY OR COUNTY WHICH REOUIRESA PERMRTO CONSTRUCT,ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE 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- FESSIONS CODE) ON THAT HE OR 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 (35DO).): ❑ I, AS OWNERCFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUBI- 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 THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE Nor INTENDED OR OFFERED FOR SALE IF, HOWEVER. THE BUILDING OR IMPROVEMENTIS SOLD WITHINONEYEAR 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). LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO DORUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS LI- CENSE LAW DOESNOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE DONTRAC- TORS LICENSE LAW). ❑ I AM EXEMPT UNDER SEC. S. A P.C. FOR THIS REASON DATE kol___ OWNER LICENSEDCONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT i AM LICENSED UNDER PROVISIONS OF CHAPTER D (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE 8USINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS —_ LIC. NO. CONTRACTOR_.— WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF T HE FOLLOWING DECLARATIONS: i HAVE AND WILL MAINTAIN ACERTIFICATE 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 REQUIRED BY SECTION 370DOFTHE LABOR CODE, FOR THE PERFORMANCE OF'rHE WORK FOR WH ICH THIS PERMIT 15 ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER -,_______ POLICY NUMBER (T)iISSEGnON NELBDNOT BE CC4A UrEDOF TEE: F EFKW IS FOR ONE MMDREDDWARS (SIOD)OR LESS) I CERTIFY THAT IN THE PFRFOPMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALLNOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUSJ ECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR COOP.., I SHALL FORTHWITH COMPLY WITHTHOSE PROVISK]NS. DATE: APPLICANT: I j WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS (5100.DDO). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I 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 [.ENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.). I LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING SCONSTRUCTION, AND HERE BY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. A I L PROWS PERMENAME (PRI ) SIGNATURE OF ERMiI TEE DATE LrD— PRESS FIRMLY APPLICATION PERMIT I r, 20� B P/C DATE_ - NUMBER # SSU1 (0 TYPE OCC DATE /�) CONST. GROUP ZONING SETBACKS FRONT RW Fl REAR U SIDE/SIDE STREET RW Cl SIDE L PROPOSED USE NO- DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garaga/Carport W Patio/Deck U- PQol/Spa Z Re -Roof Commercial _ Cal Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U U W J W I Z m J IL (Ij CA S 70A! UMAcA. F AiAt CouD Dill GLA,► l 6_& 2 U W CONSTRUCTION__ -- PLAN REVIEW ELECTRIC ..._.-. .—._... _—_.—_ PLUMBING --_..`—______ MECHANICAL _ % /•� INSPECTION FEE ISSUANCE SMIP --- '------ -- ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES 4217 COMMENTS �_ ol VALIDATION RECPT. NO. _ PAID BY _ WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GVwtNHVV—ree copy, UnttN—Appucam 5 L,opy