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Home My WebLink About18065 (25)� - - ^---_��— CIT'Y OF DIAMOND BAR �� DEPARTMENT OF COrRvfUNtI'1'&DEVELOPMENT SERVICES � � 21825 E.Copley Drive (909)860-3195 Fa�c(909)861-3117 PRESS ��<�� BUILDING PERMIT APPLICATION FIRMLY a DDRESS IfJ�J O �N� {-Jtl . DATE CATION ` / �� NU BER /��#/C v�- � o / � APN OT TRACT ISSUE �.� TYPE pCC ;�— DATE G--- CONST. GFiOUP p OWNER 1��a ✓1� � p ADDRESS ZONING SETBACKS • z CITY ZIP TEL. FRONT qyy ❑ � APPLICANT TEL. REAR ❑ �� SIDE/SIDE STREET RW ❑ CONTRACTOR SIDE ❑ ADDR S � CITY ZIP� TEL.`I��f/6�2.2HQr PROPOSED USE w G/ z SIGNER a ADDRESS •G NO.DWEL. NO. NO. � CITY ZI� TEL. � UNITS STORIES BEDROOMS � � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFlRM UNDER GEWLLTV OF PERIURV THAT I MI E%EMPT FROM THE CONTRACTORS LI- G8f0 B/C8 !I W CENSE LAW F-0RTHE FOILOWING REASON(SEC.7031.6 BUSINESS AND PROFESSIONS CODE:ANV CITY OR (n 9 � U COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG W Py110/DBCI( 3� S/ w NRE,PRIOH TO ITS ISSUANCE.ALSO REOUIRES THE APPLICMfT FOR SUCH PERMIT TO FILE A SIONED W � STA7EMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PqOVI510NS OF TI1E CONTRACTORS ll� � CENSE LAW(C}1APTER G(COMMENCINO WITH SECTqN 7000)OF DIVISqN 3 OF THE BUSINESS AND PRO- � POOI/SP8 FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDiHEBASISFORTHEALLEOEDE%EMP- (!j � TqN.M/VVqLATIONOFSECTION7031.5BVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(f600).�: � OI,ASOWNEROFiHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIR50LECAMPENSATION, ❑ COrt1rtI0fC18I - Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OP OFFERED FOR SALE(SEC.7W�,BU51- J � � NESS AND VROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPEHTV YA10 BUILDS OR IMPROVES THEREON.AND MA10 DOES Sl1CH Y/ORK HIMSEIF OR HERSEIF OR wTHiiOUGHHISORHEROWNEMPLOVEES.PROVIDEDTHATSUCHIMPROVEMENTSAAENOTINTENDEDOR m Q OFFEAEDFORSALEIF,FqWEVERTIEBNLDWGORIMPROVEMENTI550LDWITHINONEVEAROFCOMPLE� Z TION,THE OWNER-BUIIDER WILL HAVE THE BURDEN OF 7ROVINO THAT HE OR SHE DID NOT BUILD OR � IMPROVE FOR THE PURPOSE OF SALE). w ❑I,ASOWNEROFTHEPROPERTV,AME%CWSNE�VCONTRACTINOWfTHLICENSEDCONTRACTOqS � � TO CONSTRUCT THE PRRIECT(SEC.7oN,BUSINE55 AND PROFESSIONS CODE:TNE CONTRACTORS LI- V81U8llOn ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND I � WHOCONTRACTSFORSUCHVROJECTSWITHACONTRACTOR(S)UCENSEDPURSUANTTOTHECONTMC- QUANTITY DESCRIPTION FEE � TORSLICENSEIAWJ. Q ❑I AA1 EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON � ��GH U � DA7E OWNER ¢ ' 1 �� Z U � LICENSED CONTRACTORS DECLARATION w � I HEREBY AFFIRM UNDER PENALTV OF PERIURV TMAT I AM LICENSED UNDEF PROVISKKJS OF CHAPTER � � � D(COMMENCINO WITH SECTqN 7000)OF OIVISION 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z �� MY LICENSE IS W FULL FORCE AND EFFECT. m � LICENSE�C.�L-A/$6,� � � 1 G LIC.NO.�O�W� � V DATE��Z CONTRACTOR d LIJ — I ' � � WORKERS'COMPENSATION DECLARATION . � � U � I HEREBV AFFIRM UNOER 7ENALTV OF PEFL1UqV ONE OF THE FOLLOWINO DECLARATIONS: Z 0 I HAVEAND WILLMAINTAIN A CERTIFICATE OF CONSENTTO SELF-INSURE FOR WORKERS' _ � COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE UBOR CODE,FOR THE PERFORMANCE w OF E WORK FOR WHICH THIS PERMIT IS ISSUED. � O w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION Q J700 OF h1E LABOR CODE,FOF THE PERFORA/ANCE OF THE WORK FOR WHICH iH15 PERAIR IS p o ISSUED.MY KE S'COMPENSATION INSURANCE CAqRIER AND POLICV NUMBER ARE: CONSTRUCTION c L, fQ�, � CARRIER ��'M��1�� PLANREVIEW �}-/• Y� � POLICV NUMBER ELECTRIC � � (�HLSSECIKXJNE�NOTBEOOAIPLETmOFi1-IEPEFiMTISFOqONEV41�DFim00.LARS(5100)ORLESS} PLUMBING W � Z I CERTIFV THAT IN 7HE PERFORMANCE OF THE WORK FOR WHIGi THIS PERMIT IS ISSUED,I MECHANICAL U' SHALL NOT EMPLOY ANY PERSON IN ANY MANNEH SO AS TO BECOME SU&IECT TO THE (/� WOHICERS'COMPENSATION LAWS OF CALIFOFiNIA,AND AGREE THAT IF I SHOULD BECAME INSPECT�ON FEE � SU&IECT TO THE WORNERS'COM7ENSATbN PROVI510N5 0F SECTION 3700 0F THE LABOH �� CODE I SHALI FORTHWITH CAMPLV WITH THOSE PROVISIONS. ISSUANCE � p DA7E: APRICANTC��e SMIP w ��•� � ENERGY P/C J WAANINO:FAILURE TO SECURE WORKERS' OIEI�ENSATKKJ COVERAGE IS UNUWFUL,AND SHALL BE J � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDh10USAND ENERGYPERMIT OOLURS(f t00,00u),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES A$PROVIDED FOR IN J SECTION�708 OF h1E LABOR CODE.INTEREST,AND ATTORNEV5 FEES. � ✓ w RETENTION FEE: O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFIqM UNDER PENALTV OF PERJUFV THAT THERE IS ACONSTRUCTION LENDING AGENCV FOR THE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.]oB7,CIV.C.). ' Z W � LENDER'S NAME � LENDEfYS ADDRESS � ICERTIFYTHATIHAVEREADTHISAPPUCATqNANDSTATETHAT7HEABOVEINFOR/AATIONISCARRECT. TOTAL FEES ��• .y�n 0� ` �24�� I AGREE TO COMPLV WfTH ALL CITY AND COUNTV OR�INANCES AND STATE UWS REIATING TO BUILDINO I�JV � CONSTRUCTlON,AND HEREBV AUTHORIZE flEPRESEMATIVES OF THIS COUNTV TO EMER UPON THE Z ABOVE�MEIfT�IONED PROPER7V FOR INSPECTION PURPOSES. COMMENTS � �ohn /4�:�,�_ J � m PERMITTEENAME(PRINn Q � ��.��--� Jr 1 U L � R F�RMITTEE DA�- � � � RECPT.NO. PAID BY VALIDATION WHITE—DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy �� "�C��+l ��G��t� �; (��(;=��j�� . -r----�-�a--�--�.,_.,--�.�.,.v... m �,. � � {��`:r'�`7UU4=.� t� ,D � f ,�'. �a'j'� ° ��1�._.._,.�°$ ,� �t`��,�.,,�s "��-'��.��#-ff � j � �� _ � � �`�'� � z� 5ET E�ACK � �� LOOR JQ{ST � ��i�� { - � � � �� --__ �_� � -- -.--, .� ___ - �� __ ._ __ FTG�/FORfv1S/ST�E� ��L�-;�:�- �%j�. 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