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Home My WebLink About15060 (8)CITY 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 ly6b %/�'e�6YlTf t /1i31 / 1L�(/ APN LOTS TRA T OWNER ADDRESS CITY IP 71ELS/Q3/S-7l)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 T.I. CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.5 BUSINESS AND PROFESSIONS CODE ANY CIYOR COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT. ALTER, IMPROVE, DEMOUSH.OR REPAIRANY STRUO 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 FROVISIONS OF THE CONTRACTORS T. - CENSE UW (CHAPTER / (COMMENCING WITH SECTDN 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).): 13, L ASO'MHEROFTHE PROPERTY.OR MY EMPLOYEES MATH WAGESAS THEIR SOLE COMPENSATION, WALL DO THE WORK AND THE STRUCTURE ID NOT INTENDED OR OFFERED FOR SALE (SEC. 70". BUSI- NESS AND PROFESSORS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO MH 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 OHIMPROVEMEW IS SOLDWATHIN ONE YEAR OF COMPLE- TION, THE OWNERBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). - - O L AS OWNER OFTHE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH 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 WIND BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WTHACONTRACTOR(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 HEREBYAFFIRMLNDER PENALTY OF PERJURY TONT IAM LICENSED UNDER PROVISIONS OF CHAPTER f (COMMENCING WITH SECTION 70001 OF DIVISION 1 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE 15 IN FULL FORCE AND EFFECT. �+��jQ� LICENSE CLASS •J — LIC.NO. Z ZZI$ U C, DATE W> CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEUFHNSURE FOR WORKERS' ENSATION, AS PROVIDED BY SECTION 37000F THE LABOR CODE, FOR THE PERFORMANCE TONE WORK FOR WHICH THIS PERMIT 6 ISSUED. I HAVE AND WALL MAINTAIN WORKERS• COMPENSATION INSURANCE, AS REOUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS MWED. MYWORKERS' Pgl�AT10NN�CE CARRIER AND POLICY NUMBER ARE:. CARRIER POLICY NUMBER (IRIS SECTION N FMN OT BE DOMF IETEDOF7H E PERMITS FOR ONE HUNI= (1100)ORLESS) I CERTIFY THAT N 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 IN I SHOULD BECOME SUBJECT TO THE WORKERS* COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.1 SOU FORTHWrTH COMPLY WITH THOSE PRDVI SIGNS. _ DATE: '/;�=•�PLICANP. �C�� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNIAWFLA. AND SHALL BE SU aXCTAN 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 3700 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I 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. 5007. CW. C). I LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE 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 / 4, -P/C �� DATE NUMBER ✓ It ISSUE / S0 TYPE (lJ OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW L-1 ❑ SIDE ❑ PROPOSED USE ti tit i� IW 7� NO. DWEL. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. ' FACTOR PSF ADJ. AREA(VALUATION SFRIADDIREM C0 Garage/Carport 111 PatiQ1Deck - - LL Pool/Spa ZRe -Roof Commercial cc aft - Valuation ADJ.AREA QUANTITY DESCRIPTION FEE a Q F- W W T.) Z m i J a J 4 _U Z Q S U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE � �� =. SMIP "Q)')",i U'; � I/!i ENERGY P/C 7 1 ENERGY PERMIT v it > 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