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Home My WebLink About15098CITY OF DIAMOND BAR DEPART?BENT OF COMMUNITY &DEVELOPMENT SERVICES 21660 E. COplcy Drive Suite 190 (909)860 3195 Fax (909)651-3117 BUILDING PERMIT APPLICATION JOBSITE(� . ADDRESS "t APN LOT TRAqT OWNER ADD SS i• CITY I P 1TEL- APPLICANT TEL CONTRACTOR' at'r- ADDRESS CITY ZIP TEL ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL, OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRAC70RS L4 CENSE LAW FORTHE FOLLOWING REASON ISEC. 7031.5 BUSNESS AND PROFESSIONS CODE ANY CRY OR COUNTYWHNICHREOUIRESA PERMIT TOCONSTRIJCT.ALTER, SAPROVE. DEMDUSK OR REPAIR ANY STRU(, TUBE, PRIOR TO ITS ISSUANCE. ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7DOO) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP- TION. ANY VIOLATION OF SECTION ?WI .5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 13500).): O L AsOWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WALL 00 THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7041. BUSI- MSSAND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY VINO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK MIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF.HON'EYER THE BUILDING ON IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE `TION, THE OWMER49URDER 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 CONTRACTMD WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 70AN. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U. CENSE UAW DOES NOTAPPLY TORN OVMER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WAD CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRA(, TORE LICENSE LAW.), O 1 AM EXEMPT UNDER SEG B. 5 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBYAFFIR.L UNDER PENALTY OF PERJURY THAT IMI LICENSED UNDER PROVISIONS OF CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND MY LICENSE IS N FULL FORCE AND EFFECT. LICENSE CLASS LO. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _I HAVE AND WALL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS COMPENSATION. AS PROVIDED BY SECTION 5700 CF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR VA OCH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION 37Do OF THE LABDR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. MY WORK EF.T COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (MS SECTION NEED NDT BECDNRETEDOFTH E PER.TTISFOR ONE HUNDRED DOLLARS poo) OnLEs4 I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SRALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 1700 OF THE LABOR CODE.1 SMALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL• AND SHALL BE SUBJECT AN EMPLOYER TO CRM NAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS IS 100.000). IN ADDITION TO THE COST OF COM PENSATKXN. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 15 A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3097• CIV. C). I LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE TENT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUDDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER �I(N/TME, A ABOVEJAENRONED PROPERTY FOR INSPECTION PURPOSES /WI `A,K•- 1�� `HVL 1 Iran dOA vQzn - I ! PE E"ME0" INT) .\,--� T(\ \ rn 31(WTURC OF E DATE PRESS FIRMLY APPLICATIO PERMIT P/C DATE NUMBER M ISSUE TYPE OCC DATE CONST, GROUP ZONING SETBACKS FRONT RW ❑ - REAR ❑ SIDE/SIDESTREET RVf ❑ SIDE ❑ PROPOSED USE Y' Sy Z -W -M I.t NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ_ AREAIVALUATION SFRIADD/REM Garage/Carport W Patio/Deck U- PooUSpa Zno -Roof 0 Commercial - 5 to Valuation ADJ.AREA QUANTITY DESCRIPTION FEE a U H � s rd, z ,I m ` a.Iay,C.f J a JUN' 14 LUU U CT C)—.. ill A A A(1 T` I31 ITI _.. J T)TNTrr A N TT, C' A T--, 2 U W CONSTRUCTION PLjAXf1ENfIEW+� ELECTRIC PLUMBING MECHANICAL E�CFNFEE e� v ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES "�eNTsCIV, c , RECPT. NO. PAID BY VALIDATION '— WHITE—Department Copy, YELLOW—finance Copy, PINK—Aseesaor Copy, GOLDENROD—File copy, GF E COPY - I