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Home My WebLink About15001 (20)didllll�ll It.11: � :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 APPLICATION JOBSITE ADDRESS�� Z- f��AAL APNT T ACT OWNER AD S �N � CI I APPLICANT CO AD4x- alf%4 C E ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM LNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U• CENSE LAW FOR THE FOLLOWNO REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY V"CHI REOUIRESAPERMRTO CONSTRUCT. ALTER IMPROVE. DEMOLISH, OR REPAIRANYSTRUC- TURF, PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED STATEMENT THAT HE OR SHE S LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW ICHAPTER 6 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FORTHE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FINE HUNDRED DOLLARS 111600).1: O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL 00 THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUST• NESS AND PROFESSIONS CODE: THE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUIDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROLX7H MS OR ITER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE TION. THE OANERFBIBLOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DIE) NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} O LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS L6 CENSE UW DOES NOTAPPLYTO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(5) LICENSED PURSUANTTDTHE CONTRAC- TORS LICENSE LAW } wXL- EXEMPT UNDER SEC B. I P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBYAFFI M UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 6 (COMMENCING WITH SECTION 7000) OF DMSION 3 O THE BUSINESS BBUSINESS AND PROFESSIONS CODE. AND ULICENSE S N 2!1`Oq�F�TIO EFFECT. UC NO " — 9" DA�/��c�J�/G'' CONTRA WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PER.URY ONE OF THE FOLLOWING DECLARATIONS: __I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT S ISSUED. i —I HAVE AM WILL MAINTAN 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: I CARRIER POLICY NUMBER i (DS SECTION NEED NOT BE COMPLETED OF THE KRMITSFDA ONE HUNDRED DOLLARS R+m1DRL6.s} I CERTIFY THAT N THE PERFORMANCE OF THE WORK F HI THIS P . IS IS ED.1 1 SMALL NOT EMPLOY ANY PERSON IN ANY MANNER TOB EJECT HE j WORKERS COMPENSATION LAWS OF CAUFORNI*. DAGRE HA IF BECOME SUBJECT TO THE WORKERS! COMPENSATION P. VISION 37000E THE LABOR TiTIINRiII nDF SHAIl�i� COMPLY WITH ION G n� 1 DA LTT APPLIQANr ' WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE ISAND SHALL13E SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ON UNOR AN THOUSD DOLLARS (81 D0.000). N ADDITION TO THE COST OF COMPENSATION, pAMAOE AS PRO EO FOR N i SECTION 37060E THE LABOR CODE. INTEREST. AND ATTORNEYS FEES. I CONSTRUCTION LENDING AGENCY i FOR THE AFFIRMUNDER PENALTYOFPEONRYTHATTHEREMACONSUED(S C. 097, CIO AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3037, CIV. Q). 3 " LENDER'S NAME LENDERS ADDRESS 3 I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT, I AGREE TO COMPLY WITH ALL CIT/ AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION• AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNT.V70 EWEA VPON THE ENTIONED PROPERTY FOR INSPE S. � PERMIrrE wNn J r7 SIGNATURE ERI DATE C EXPIRED JUN 19 2002PRESS FIRMLY APPLIDATE2 �/ n t 5040 PIC NUMBEPERMI DATE 7"� NUMBEFI ,/�� 0 ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDESTREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM GaragoMarport W PaCw/Deck LL PooVSpa Z Re•Ro01 0 Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U 4.r U uj Z CO J a J a U Z S W CONSTRUCTION PLAN REVIEW ELECTRIC MECHANICAL INSPECTION FEE MAY _2 f ISSUANCE n 9090 SMTP ENERGYP/C r,.__ t' ND BAR �LIMAXNU AND SAFETY ENERGYPERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEESC� v COMMENTS VALIDATION RECPTRECP . NO. BY VALIDATION riment Copy, YELLOW—Finance Copy. PINK—Assessor Copy, GOI.DLNHOo--rue L:opy, UKhhr—npp1icanrs L;4W