HomeMy WebLinkAbout18888 1� __ CITY OF DIAMOND BAR
� DEPARTMENT OF COIW�fUN1TY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive PRESS
(909)860.3195 Fax(909)861-311�
,'"`" BUILDING PERMIT APPLICATION FIRMLY
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DOLLARS(5700.0001.IN ADDITION TOTHE COST OF CAMPENSATION,DAMAGESAS PROVIDED FOR IN
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d FOR THE PERFORMANCE OF THE WORN FOR WHICH TMIS PERMIT IS ISSUED�SEC.3087,CIV.GJ.
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ocft 210**
1!t�
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
ADDRESS}� 1-y I! 61ti11 N �;
ADDRESS
TRACT
APN LO_
T
OWNERI
ADDRESS
CITY ZIP TE.401, 1
APPLICANT-TEL.
CONTRACTOR
ADDRESS An X
CITY ZIP 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 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA 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 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
0 I.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH 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 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 NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF 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).
^ 1,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70". BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH AC NTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OW
LICENSED CONS DEC TION
I
I HEREBY AFFIRM UNDER PEENALTY OF PERJULICENSED ER PROVISIONS OF CHAPTER
SVE
9(COMMENCING WITH SECTION 7000)OF DIVBUSINESS Ib PROFESSIONS CODE.AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATINJS:
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 REQUIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER_
(THIS SECTION NEED NOT BE ODMPLETEDOF THE PERMIT IS FOR ONE HUNDRED DOLLARS(8100)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 FOFITHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(8100.000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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
I 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 HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE DATE
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APPLICATION PERMIT/C
DATE NUMBER#
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE I r E'X'-fl.'
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
w Patio/Deck
LL PooVSpa
Z
Re-Root
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
W
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W
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IL
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0
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CONSTRUCTION ?U.
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: �.
PRE-ALT FEE:
TOTAL FEES 7
COMMENTS
RECPT. N0. RMVIPAIDBY VALIDATIO
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy