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Home My WebLink About14973CITY 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 ADDRESS -i �11� �G �'1 0 C� APN rLOT TRACT OWNER ADDRESS CITY wn ZIP "i I' 8 a TEL. E`LeS 34 APPLICANT 01LI,112 TEL CONTRACTOR ! :� !!- F,(� :' l�,• ADDRESS 14-3921- < CITY :LTA K ZIP 4. rTEL 114 i q:)-,'7:1 < ARCKTNG1 DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LL CENSE LAW FOR THE FOLLOWING REASON (SEC.?WI.5 BUSINESS AND PROFESSIONS CODE ANY CRY OR COUNTYWIF ICH REDURESA PERMIT TO CONSTMIC7,ALTER.IMPROVE. DEMOUSH, OR REPAIRANY STMJr, 7URE. PRIOR TO RS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE UAW (CHAPTER I (COMMENCING WITH SECTION TODD) OF DIVISION S OF THE BUSINESS AND PRO- FESSIONS OWE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.6 BY ANYAPPLICANT FOA A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6500).): D LAS OWNER OF THE PROPERTY. OR MYEMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE YORK. AND THE STRUCTURE IS NOT MENDED OR OFFERED FOR SALE (SEC. 70«, BUSI- NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BULDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HEROMN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF. HOWEVER, BU THE aONGOR IMPROVEMENT IS SOLD WRHNCNEYEAR OFCOMPLE- TIOH. THE OWNER-IUILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FORTHE PURPOSE OF SALE} D LAS OWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC 7044. BUSINESS AND PROFESSIONS COOS THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC• TORS LICENSE LAW). D IMI EXEMPT UNDER SEC B. t D.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER P (COMMENCING WITH SECTION 7000) OF DMSKN 7 OF THE BUSINESS AND PROFESSIONS COD E. AND MY LICENSE IS N FULL FORCE AND EFFECT. ,r LICENSE CLASS `� UC. NO. v DATE S� I'T �` 'C'- CONTRACTOR 'S •�! C. i WORKERS' COMPENSATION DECLA N I HEREBY AFFSGLI UNDER PENALTY OF PERJURY ONE OF THE FOLL NG i I _I HAVE AND WILLMANTAN ACERTIFICATE OF CONSE 0SELfN�OR S' I COMPENSATION. AS PROVIDED BY SECTION 37000E E LABOR CODE. FOR THE PERFO ANGE F THE WORK FOR WHICH THIS PERMIT IS ISSUED. I I HAVE AND MILL MAMTAN Y/ON<E.'COMPENSAT. URANCE, AS 3700 OF THE U1BOR CODE• FOR ME PERFORMANCE OF TH H THIS PERMI LSSUEO. MY WORKERS' COMPENnSATION INSURANCE CARRI POLICY NUMB I CARRIER 't V POLICY NUMBER c MIS SECTION NEED NOT BE fAAEuTED OF THE BFOROPEH. DREDDOUAAS 100)OR I I CERTIFY THAT N THE PERFORMANCE OF THE WORK ERMITIS S 1 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO YORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD B E SUSJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR CODE I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. T DATE:: —I>? —G a APPLICANT: iWARNING: FAILURE TO SECURE WOFNKERS'COMPENSATION COVER GEOU1 WFUL. RANO SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($IW.000), N ADDRION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN J SECTION 37060E THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. J CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE PENALTY OFPERJURYFOR WHICH THAT THERE MIT CONSUED(SEC. LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 9007. GV C). J - LENDER'S NAME LENDERS ADDRESS L C 1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. U IAGREE TO COMPLY WITH ALLCITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING L` CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPONTHE ASOVEdAEWK)NED PROPERTY FOR INSPECTION PURPOSES. 5 M a wv PERMITTEE NAIYE (PRINT) A) SIGNAT R F,/I ITTEE DATE C PRESS FIRMLY APPLICATIO \ Uv PERMIT )411PIC __ DATE VV NUMBER L 1 N ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSEDUSE Ettr G,F `Com 54G+ Ij 3 NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTORPSF ADJAREALVALUATION SFR/ADD/REM Garage/Carport W Patiof0eck U- POOVSpe ZRe -Root OJ Commercial 5 LD Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U w J w 0 Z 01 J W r � CONSTRUCTION LAN REVIEW ELECTRIC PLUMDING MECHANICAL INSPECTION FEE ISSUANCE T) SMTP ENERGY P/C ENERGYPERMIT�� — RETENTION FEE: IDB L L', PRE -ALT FEE: . +.STI AFE BUIL TOTAL FEES r COMMENTS RECPT. NO. PAID B VALIDATION WHITE—Department Copy, YELLOW—Finance Copy. PINK—Assessor L:opy, uuwt_Nmuu ije wPy. an m—Pp-1 s -Py