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Home My WebLink About14959CITY OF DIAMOND BAR - DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES w 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION _ ADDRESS o i r APN 'LOT TRACT OWNER AD S lqox 15et'll"s W, CITY ✓ Zt TEL. APPLICANT TEL. CONTRACTO 1. ADDRE CITY EL. ARCWENG/ 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 FORTHE FOLLOWING REASON (SEC. 7D31.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIHESA PERMITTO 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 B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR 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 A CIVIL PENALTY OFNOT MORE THAN FIVE HUNDRED DOLLARS (5500) ): ❑ 1, AS OWNER OF THE PROPERTY, OR MV 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 FORSALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- TK7N, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD 4R IMPROVE FOR THE PURPOSE OF SALE). ❑ I, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, 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 ACONTRACTOR(S) LICENSED PURSUANT70THE CONTRAC- TORS UCENSE LAW.). ❑ IAM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER s (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FUL ORCF AND EFFECT. �% / f LICENSE d LIC. NO. + ^'7� �,("� 7l q DATE 6� CONTRACT'OR%N_. WORKERS' COMPENSATION DECLARATI I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: �✓ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OFT HE 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 =R-MYWORKEfS(X IPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: !` A✓//�! POLICY NUMBER ��Y f (THIS SECTION NEED NOTES COMP_E MOFTHE PERMIT IS FOR ONEHUNDREDDOLLARS ($100) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISI(,)GJS OF SECTION 370D OF E LABOR LADE I SHALL FOfTfFIWITH COMPLY WITH THIS 1GL1111 DATE: APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COMPENS N COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND COIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($10,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097, CIV C-). LENDER'S NAME LENDERSADDRESS 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 ST RUCTION, AND HEREBVAUTHO REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE -MENTIONED PROPERTY FOR IN 474R.SpION PURPOSES. t �,P RMYfTEENAME(PFI- / SIGNATUR ERMITTEE I DAT PRESS FIRMLY APPLICATION5.� �� PERMIT `' P/C DATE ✓ NUMBER # ISSUETYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM (1) Garage/Carport W Patio/peck UL PDoUSpa 0 Z Re -Roof Commercial 5 fb Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U F U W J LU GD Z m f a Q U_ Z W _ CONSTRUCTION PLAN REVIEW ' ELECTRIC PLUMBING MID MECHANICAL INSPECTION FEE ISSUANCE MAY 15 2000 = �-- SMIP CTT_Y OF DIAMONDBAR ENERGY P/C 4(,.)ILDIING AND SAIfE 1, ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES COMMENTS 72 Inz RECPT. NO-Zo - PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy ,., ,:• w .: �, , . K . s .. .