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Home My WebLink About14913�i 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 ADDRESSa?,lDI 3H 1 0 K. D R APN LOT -TRACT OWNER ADDRESS 2( �� PIZ CITY Qui^_� ZIP TEL APPLICANT TEL. ST CONTRACTOFj o ADDRESS -Alt- CITY n A-&JyAf� ZIP Q,�' TEL ARCRSNG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFR U UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE UW FOR THE FCLLOWNG REASON (SEG 7051.5 BUSINESS AND PROFESSIONS CODE: ANY CRY OR COUNSY VMIGI REQUIRES APERMR TO CONSTRUCr.ALTER.MPROVE. DEMOUSK OR REPAUflANY STflt1G TUBE, 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 L4 CENSE UW (CHAPTER v (COMMENCING WITH SECTION 70(30) OF DIVISION S OF THE BUSINESS AND PRG FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP• TION. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS CIL AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT MENDED OR OFFERED FOR SALE (SEG 7044. BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTYWMO BUILDS on IMPROVES THEREON. AND WHO DOES SUCH VOR( HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THATSUICH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE G. HOWEVER THE BUILDHNO OR IMPROVEMENT IS SCD WITHIN ONEYEAR OFCOMPUE- TION. THE OWNERBUILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR IMPROVE FORTHE PURPOSE OF SAIF). O L AS OWNER OF THE PROPERTY, AM EX0.USNELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS L4 CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH CONTRACTOR(S) LICENSED PURSUANT TO ME CONTRAG TORS LICENSE LAW J O IMI EUKEMPT UNDER SEG B. S P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRMUNDER PENALTY OF PERAIRY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER e MOWAENCM WUH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE cONTRACTOR�I •,s2[1[g e WORKERS' COMPENSATION DEC VLARA7 TION I HEREBY AFFaW UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _I HHAYE AID WILL MAN7AN ACE --TE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WOPoQRS• COMPENSATION INSURANCE, AS REQUIRED BY SECTION 5700 OF THE LABOR PDE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ` ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUM DER ARE', CARPER 5^T/ IX - T -u 1/1)/ ))) POLICYNUMOEF IMS SECTION NEED NOT BE ODIAR ETEDOFTH[ KAX9T B FOR ONE HUNDRED DOLLARS (3I00)OR LESS) I CERTIFY THAT N THE PERFO MMCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I 1 SHAILNOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE j YORKERS' COMPENSATION LAWS OF CAUFORTHIA AND AGREE THAT IF I SHOULD BECOME BJ SUECT TO ME WOOKERS'COMPENSATION PROVISIONS OF SECTION 57DO OF THE LABOR H E FORTHWITH COMPLY VAIN THOSE PROVISIONS.DATE: �IYfA7 APPLICANT`.ENG:1.SSEECURE WORKEFS COMPENSATION COVERAGE RS UNLAWFUL, AND SHALL BE UBJECTAOYER TO CRMNAL PENALTIES AND CMLFW ES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.000). N ADDITION TO THE OOSTOF COMPENSATION. DAMAGES AS PROVIDED FOR K i SECTION 5705 OFTHE LABOR CODE. HTEREST,ADATTOnNM FEES. CONSTRUCTION LENDING AGENCY t OR THEAFFIRMUNDER PENALTY OFK FOR YTHAT THEREIS MACONSUED(SGN LENDING AOENCI' FOR THE PERFOIVAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 7017, GV. G). - LENDERS NAME LENDER'S ADDRESS J AGRETIFYE COMHAT I PAVERFALILCITYAIS APPLICATION STATE THAT ORDINANCES STATE LAWSINFORMATION T COILDIN I AGREE TO COMPLY YARN All CITY AND COUNTY ORDNANCFS ANO STATE LAWS RELATING 70 BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTONED PROPERTY FOR INSPECTION PURPOSES. PERMITTEE RNA) n n WNATURE PE TT PRESS FIRMLY APPLICATI N PERMIT PIC �� DATE Fz7 NUMBE ISSUE oo TYPE OCC DATE CC GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW 13 - SIDE ❑ SIDE PROPOSED USE b NO. DWEL, NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREANALUATION SFRIADD/REM Garage/Carport W Patio/Dock U- POOVSpa ZFlo-Rool Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE Q . IM U -1 W 0 2 m a U Z Q U W CONSTRUCTION��- PLAN REVIEW - ELECTRIC PLUMBING MECHANICAL INSPECTION FEE 40 L7v ISSUANCE � SMIP ENERGY P/Cf J j ENERGYPERMIT V �— H RETENTION FEE: A PRE•ALTFEE: - -- f TOTAL FEES �� V COMMENTS RECPT. NO. PAID BY VALIDATION M/h11TE—Department COW YELLOW--Flnanoe CON. PINK—ABasaaa WW. �vwelvnvl,—. Iw wPy, unc�.—.wlr�•� s wR•7 - 0