HomeMy WebLinkAbout15076 (17)aDIXIII)UI XIII)ND II11i
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190 +
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION , - I i FIRMLY
JOBSITE
ADDRESS /Q3 AA %r L� e
APN LOT TRACT
OWNER L E L I r -1y C
ADDRESS `17 'c, -a+✓ = �[> (I
CRY f)AM;rL+l1 "Ar, ZIPTEL.
APPLICANT G' TEL. �?
CONTRACTQR, /in �� <'�►� i
ADDRESS
CITY A JORl(+ ZIP _ 11L _TEL. <!417 3f/rfi'S
ARCFVENG/ TILL VV
DESIGNER
ADDRESS
CRY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PCRURY THAT. 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOW' NG REASON (SCC. 7031 S BUSINESS AND PRO=ESSIOHS CCCC ANY CITY CR
COLIMYWHOMREOUIFIF.SAPERMRTOa)%STRUCCALTER.IMPROVE.DCLIOL19LORPCPA IANYSTRUC-
TUAF. PRIOR TO RS ISSUANCE. ALSO WQUIRTS TME APPL=T FCn SUCH PL'RMIT TO FILE A S.GNCD
STATEMENT TA' HE 011 SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER 0 (COMMENCING WITH BECTON 7000) OF D'V.SION 3 O THE DUS. NESS AND PRO-
FESSON5 CODE) OR TUT RIC On SPIT: 15 EXEMPT THEREFROM AND THE BASIS Fon THE ALLEGED EXEMP-
TION. ANY YOLATION OF SECTION F031.5 BY ANYAPPLIGANT FOR A PERM:T SUBICC7.5 TIIE APPLIOANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNCRED DOLLARS (SW01 )'
O LAS OWNEROF T14E PROPERTY, ORMYEMPLOYEES WITH WAGESAS THE TISOLE COM,'[%SATION,
WILL DO THE WORK. AND THE STRUCTURE IS NOT IN: EKED OR OFFERED FOR SALE ISEC 7-44. BUS:
NESS AND PROFESSIONS
CODE. THE CONTRACTORS LICENSE UW DOCS NOT APPLY TO AN OWNER OF
PROPERTY WI O BUILDS OR IMPROVES THEREON. AND WIO DOES SUCH YANK HIMSC:F On HERSELF OR
THROUGH HSS OR HEROVM EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED On
OFFERED FOR SALE.F,NOWEVER THE BUILDING OR IMPROVEMEM IS SOLD 'WI HNOICYEAROFCOMPLC-
TON. THE OWNER BUILDER WILL. HAVE THE BURDEN OF PROVING THAT HE On SHE DO NOT BUILD Olt
IMPROVE FOR 111EPU PO SE OF SALE).
C)LASOWNEROFTHE PROPEMY,AM EXCLUSNL'LYCON:RACT.NGW. HLICENSEDCCNTMC70RS
TO CONSTRUCT THE PROJECT (SEC. 7541 BUSINESS AND PnoFESSONS CODE THE CONTRACTORS LL
CENSE LAW DOES NOT APPLY TO AN OWN[R OF A PROPERTY WHO BUILDS OR IMPHOVES THEREON. ANTI)
WOO COW RAC'TS FOn BUCH PRLAUCCT S WITH A CONTRACTDRIST LKENSCD PURSUANT TO THE CONTRAC-
TORSLICENSE LAW }
D IAM EXEMiTUNDER SEC. B 1 P FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PCrLJUrrY THAT I AM LICENSED UNDER PROVISIONS CF OIAPTER
I (COMMENCING WITH SECTION TOOL) OF DIVISION 7 OF THE B.:S:hCSS AND PROF -F SSON S CCCE. AND
MY LICENSE 15 N FULL FORCE AND E FFECT.
LICENSE CLASS �_'�-?/ LIC. NET F'>' ` �i •`-�
DATE C� J� CONTRACTOR ; ,
WORKERS' COLOPENSATION DEC RATION
I HCRCOY AiiItA1 UNDER PENALTY Oi' PERA:M ChC OF ME FOLLOWING DCCLAMT
_I HAVE AND WILL MAINTA:N A CERTIFICATE CF CONSENT TO SELF-PISUREF XOP'FIT
ODUPENSA'ON, AS PPOV..7ED BY SECTION 7170 OF TIC LABOR
CODE. FOF1 •E PE IFCRMAN..E
OF THE WORK FOR WHICH 7H'3 PERMIT G ISSUED.
_INANE AND WSLMA' NTA:N WORKEA�CTMPCNSA7CH INSURANCE. AS REOII 'D BY BECTON
3f000F DME LA On CODE. FOR THE PCRFCRMANCE OF THE Won✓. FOR WM:O1 eS PERM:T IS
ISSUED. MY WORKERS'IXWPCNSA7TGN; INSURANCE CKI'VER AND POLICY M.IMD.I
,I_ "
CARR:CR
POLICY NUMBER
(TMS SECTCN PLED NOD K CMV-rTC) Or T E PEIRR E FCR OF!_F ILPLW:) DOL' 47, S:xIORLEis;
I CERTIFYT14AT N THE PERFORMANCE OF THE WORK Ton WHICH THIS PEnM:T IS ISSUED, 1
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU!I.ECT TO THE
W7nKERS'COM•'ENSA7ON LAWS OF CALTOFIKIA. AND AGREE THAT IF I SHOULD BECOME.
SUBJECT TO INC WORKERS' CCMPENSATIDN PRLK`SKXNS OF SECTION 3700 OF THE LABOR
COO ,- L FOnTWr:TH COMPLY W -TM PF%OVISONS
GATE A�1 L APPLICANT.
WARNING FAA UPC TO SECURE WORKERS' COMPENSATION COVERAGE IS UN.AWTU. AND SMALL BE
SUILIECT AN EMPLOYER TO CR ANAL PCNAL1:ES AND CML FNES UP TO ONE HUNDRLD 1HOUSAND
DOLLARS (5100.000). IN AODITON TO THE COST OF COMPENSATION, DANA 305 AS PROVDED FOR IN
SECTION 37M OF THE LASOn CODE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDLNG AGENCY
1 HFRrBY ArFInM UNDER PENALTY Or PETJURY THAT TIE RC 15 A CoNSTnucTIO N LENDING AGENCY
FOR 71-C PERFORMANCE OF THL WORK FOR WTI:OI THIS PE RM:T 13 ISSUED ISEC 3007, C:V C.).
LENDCRS NAME
LENCERSADDRESS
:ccRTIFYTHATIH .E CADTH:3APPLIOAIIONANO STATE THAT THE ABONC NrOFMATION 15 CORRECT.
I AGREE W H ALL CITY AND COUNTY OP WANCES AND STATE LA's RFLATNO TO BUILDING
CONS7P' TIOI.WC IERCBY AUTHORIZE REPRESENTATIVES OF THIS CCUNTY TO ENTER UPON THE
AROVE K:;;7 FOP INSPECTION PUPPOSES.
/p�/SFA (eq NAME (PRINT)
I SIGNATURE OF PCRTAITIEE DATE
APPLICATION(/� � PE IT l� G�/� P/C
DATE v " NUMBER t N
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACK
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE p
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ. AREAIVALUATION
SFFL'ADD.'REM
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QUANTITY DESCRIPTION FEE
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RETENTION FEE'
PRE -ALT FE0V]`""' L
TOTAL FEES
COMMENTS
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RCCPT NO. PAID DY VALIDATION
Mill E—DePanment CGPy. YELLOW--Fnsnce Copy. PINK—Assessor Copy. GOLDENROD --Fila Copy, GREEN—Applicant's Copy
CITY OF DlAMIOND.BAR
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