HomeMy WebLinkAbout17568 _J�` _ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTII'&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
�"%�M�� BUILDING PERMIT APPLICATION FIRMLY
JOBSITE �_I�e� 15�(� /1�A�I� fl•Il �Sl?�+
� Q� APPLICATI9 PERMIT P/C
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER•BUILDER DECLARATION SFR/ADD/REM
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p I HEFEBV AFFlRM UNDER PENALTY OF PERNRV THAT I M/E%EMPT FROM THE COMRACTORS LI- G8f89B/CBfPOR
W CENSELAWFORTHEFOLLOWINOREASON(SEC.703t.5BUSINESSANDPROFES5KKJ5CODE:MIVCITVOR (n
U �Jp/J�'W�{ICHRC-0UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEAIOLISH,ORREPAIRANVSTRUC- W
W NRE,PRpR TO RS ISSUANCE,AL50 REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FIIE A SIONED w P8110/DBCI(
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(CHAPTER e(COMMENCWQ WITH SECTION 7oa0)OF DIVISION 7 OF THE BUSINESS AND PRO- LL POOUSPB
^ FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT 7HEREFROM AND 7HE BA515 FOH THE ALLEOE�E%EMP- (!3
V TION.ANY VIOLATION OF SECTION 7031.5 BY ANV APPLICAM FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
A CIVIL P�.N/LLTV OF NOT MORE THAN FIVE HUNDRED DOLIARS(5500).):
Z �fASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COff1ff10fC18I r
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED fOR SALE(SEC.7W�,BUSI� J
N NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF � I
PROFERTY WFiO BUILDS OR IMPROVES THERE-0N,AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR
CC THROUQM HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT IMENOED OR m
� OFFEpEDFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEAIENTISSOLDWITHINONEVEAROFCOMPLE-
Z TION,7HE OWNER-BUILDER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT BUILA OR .
� IMPROVE FOR THE PURPOSE OF SALE). '
w ❑I.AS OWNEF OF THE 7ROPERTY,AM EXCLUSIVELY CONTRACTWG WITH LICENSED CONTRACTORS � '
� TO CONSTRUCT THE PR0.IECT(SEC.�0/4,BUSINESS AND PROFESSIONS CODE THE CANTRACTOqS LI- V81U8�1Of1 ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYNM1iOBUILD50RIMPROVESTHEREON,AND �
� MM1IOCONTRACTSFORSUCHPRQIECTSWI7HACONTRACTOR(S)LICENSEDPURSUANTT07HECONTpAC- QUANTITY ESCRIPTION FEE
Y TORS LICENSE LAW.).
0 O I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� DATE OMMER H
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � T
d o(COMMENCIMO WITH SECTION 7000)OF DNISION 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z V
`X MY LICENSE IS M FULL FORCE AND EFFECT. m
� LICENSE CLASS LIC.NO. �
V DATE CONTRACTOR a
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�' WORKERS'COMPENSATION DECLARATION Q
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� I HEREBV AFFIRM UNDER PENAI.7V OF PERIURV ONE OF THE FOLLOWING DECIARATIONS: Z '
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' a
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COMPENSATION,AS 7ROVIDED BV SEC710N 370o OF THE LABOF CODE,FOR THE PERFORMANCE U
OF THE WOH)(FOR WHICH THIS PERMIT IS ISSUED. W
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W _1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION ///���
Q 37000F THE LABOR CODE,FOF THE PERFORMANCE OF THE WORN FOR WHICH 7HI5 PERMIT IS I ��. '�/�
J ISSUED.MV WORKERS'COM7ENSATION INSURANCE CARRIER M1D FOIICV NUMBER ARE CONSTRUCTION. . �v
j CMRIER PLAN REVIEV✓
POLICY NUMBER
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE WAIT IS ISSUED,1 MECHANICAL J �
GJ SHALL NOT EMPLOV ANV 7ERSON IN ANV MANNER 50 AS TO BECOME SU&IECT TO THE
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIqlWD AOREE THAT IF I SNOULD BECAME INSPECTION FEE
SUBJECT TO THE WORNERS'COMPENSATqN PROVISIONS OF SECTION 3700 OF THE LABOR
'�j CADE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. �SSUANCE �
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p DA7E: APPLICANT. SMIP . v�
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J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATqN COVERAGE IS UNUWFUL,AND SHALLBE ENERGY P/C
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� SU&IECTAN EMPLOVERTO CRIMINAL PEN/U.TIES AND CNIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(S10o.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
aC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� 1 HEREBV AFFIRM UNDER PENALTY OF PERJUFV THAT THERE IS A CONSTRUCTION LENDING AGENCY
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3ao7,CIV.C.).
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� LENDER'S NAAIE
F— LENDERSADORESS
w I CERTIFV THAT I HAVE READ THIS APPUCATION AND STATE THAT iHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES ��� �� •/�
� I AGREE TO COMPLV WITH ALL CITY AND CWNTV ORDINANCES AND STATE lAWS RELATING TO BUILDINO ��A• '�
� CONSTRUCTION,AND HEREBV AUTI-N)RIZE REPRESENTATIVES OF THIS CAUNTV TO ENTER UPON THE 'JLJ`,�7 �n/
Z ABOVE-MENTION/ED PROPEATV F!OR INSPECTqN PURPOSES. COMMENTS ��AC. _� 'Y / �T �
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SLAB GRADE FIREPLAGE FpU�IDpTION �
TEMP P.OWER FlREPLAGE BONQ BEAM
WATER SERVICE MID HT. F30ND BEA(vi
ROOF SHEATHING 8 FT. BONO BEAM
FRAM[NGNENTI�tATtON FINAL BOND BEAivt
ROOF COVER ^ PRE-GRADING
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ROUGN ELECTRIC ' �3 � - ROUGH GRADING
ROUGH PIUtVIBING -� FINISH GRADING `
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EXT. LATH/SIDING , POOL FENCiNG G, ^�_ .
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