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Home My WebLink About15060CITY OF DIAMOND BAR' DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 M BUILDING PERMIT APPLICATION _ JOBSITE ADDRESS APN LOTS TRACT OWNER ADDRESS CITY IP 7TEL.7/0-365-71)7y APPLICANT TEL CONTRACTOR ,ADDRESS C ZIP TEL5jF 0,R • f:!(2Z 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 FOR THE FOLLOWING REASON (SEG 7031.5 BUSINESS AND PROFESSIONS CODE ANY CIYOR COUNTY WHICH REQUIRES A PERMI TTO CONSTRUCT, ALTER, IMPROVE. DEMOUSH.OR REPAIRANY STRUC. TUBE. PRIOR TO ITS ISSUANCE, ALSO RECUtRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE FROVISIONS OF THE CONTRACTORS UI- CENSE 4CENSE UW (CHAPTER 1(COMMENCING WITH SECTION TODD) OF DIVISION 1 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 CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (1500).): O L ASO'MNEROFTHE PROPERTY.OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WLL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". 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 HERSELFOR THROUGH MS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF. HOWEVERTHE BUILDING ORSAPROVEMEW IS SOLD WITHIN ONE YEAR OF COUPLE - TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALU - - O L AS OWNER OFTHE PROPERTY, AM EXCLUSIVELY CONTRACTING ED G H LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 70N, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U• CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITHAOONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC. TORS LICENSE LAW). O 1 AM EXEMPT UNDER SEC. S. a P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBYAFF'IiM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER t (COMMENCING WITH SECTION 70001 OF DIVISION 1 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. �+��jQ� LICENSE CLASS •J — LIC.NO. Z ZZI$ U C, DATE 77% corrrRAcroR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WUL MMNTAN A CERTIFICATE OF CONSENT TO SELFNNSURE FOR WORKERS' ENSATION, AS PROVIDED BY SECTION 17000F THE LABOR CODE, FOR THE PERFORMANCE TONE WORK FOR WHICH TMS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS• COMPENSATION INSURANCE, AS REQUIRED BY SECTION 5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' Pgl�AT10NN�CE CARRIER AND POLICY NUMBER ARE:. CARRIER �L/��_/J/ POLICY NUMBER (THIS SECTION NEEDNOT BE OOAii=OFTHE PDM.MTIS FOR ONE FL*CRID DOLLARS (5100)ORLESS) 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. H SWILL NOT EMPLOY ANY PERSON N 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.1 S FORRT1�W--RT�H COMPLY WITH THOSE PROVISIONS. _ DATE: 5;�PLICANP.iZ_zlf�� WARNING: FAILURE TOO SECURE WORKERS' COMPENSATION COVERAGE IS UNIAWFUA. AND SHALL BE SUaXCTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (1/00,000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 5700 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 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. 7007. CW. O). I LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. (AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULGING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. i PERMITTEE NAME (PRINT) _ SIGNATURE OF PERMITTEE VTE 1 PRESS FIRMLY APPLICATIO 3 YUPERMIT if 4, -P/C �� DATE NUMBER ✓ It ISSUE / S0 TYPE (lJ OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW L-1 ❑ SIDE ❑ PROPOSED USE ti tit riNO. IMHj DWEL. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. ' FACTOR PSF ADJ. AREA(VALUATION SFRIADDIREM Garage/Carport WPatiQfDeck - - LL Pool/Spa ZRe -Roof Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE a Q W W C) Z m i J a J 4 _U Z Q S U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE 7, ISSUANCE N jf • •�� =. SMIP fl(j i U'; � v I/!i ENERGY P/C 7 if1 ENERGY PERMIT v > RETENTION FEE: L PR TOTAL FEES CO NTS {wn� RECPT. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy PINK—Assessor Copy, GOLDENROD—File Copy, GREEN --Applicant's Copy