HomeMy WebLinkAbout15076 (19)aIII)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 If r -1y C
ADDRESS `1' 'c, -a+✓ = �[> (�_
CITY I)Ar";yVi "Ar, ZIP ' _zjTEL. P,` / Yy
APPLICANT G' TEL. %�
CONTRACTQR, /in �� <'�►� i
ADDRESS r --. -` L�
CITY MOLT Rl(+ ZIP _ 11L _TEL. <!417 3f/rfi'S
ARCFVENG/ ILL VV
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PCRURY THAT. 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOW' NG REASON (SCC. 7031 F BUSINESS A40 PRO-ESSIONS CCCC ANY CITY CR
COLIMY M*M REOIIIFIF.SA PERMR TO a)%STRUCCALTER.IMPROVE. DCMIDLISHI.OR RCPA RANY S TFr �C-
PRIORJRE. PRIOR 70 RS ISBUANCE. ALSO RFGDIRCS THE ADPLMJVNT FCR SU^JI PL:RMIT TO FILE A S.GNr.7
STATEMENT THAT HE 011 SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER 0 (COMMENCING WITH BECTON 7000) OF D'YLON 3OF THE OUS. NESS AND PRo.
FESSIDNS CODE)OR TUT RIC On SPIT: IS EXEMPT TMCREFFIOM AND THE BASIS Fon THE ALLEGED EXEMP-
TION. ANY YIO ATIDN OF SECTION F031.5 BY ANYAPPLICANT FORA PERMIT SUB.TCCTS TIIE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNCRED DOLLARS (SW01 )'
CLAS OWNEROF T14E PROPERTY, OR MY EMPLOYEES WITH WAGES AS THE Ft SOLE COM,'[%SATON,
WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. 7--44. BUS:
NESS AND PROFESSIONS
CODE. THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WI O BOLDS OR IMPROVES THEREON. AND WINO DOES SUCH YANK HIMSC:F CR HERSELF OR
T ROICII HSS OR HEROVM EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED On
OFFERED FOR SALE. F.MOW EVER, THE BUILDING OR IMPROVEMCM IS SOLD -WITHIN ONE YEAR OF COM --LC.
TION. THE OWNER BUILDER WILL. HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT B'UI'LD Oft
IMPROVE FOR 111EPU PO SE OF SALE).
CLASOWNEROFTHE PROPErrTY,AM EXCLUSNL'LYCCN:RACT.NGW. HLICENSEDCCNTMC7OlS
TO CONSTRUCT THE PROJECT (SEC. 7541 BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LL
CENSE LAW DOES NOT APPLY TO AN OWN[R OF A PROPERTY WHO BULLS OR IMPHOVES THEREON. AND
WINO COW RACTS FOn BUCH PRL)UCCT S WITH A CONTRACTORIST LKENSCD PURSUANT TO THE CCN4RAC-
TORSLICENSE LAW }
C IAM EXEMiTUNDER SEC. B 1 P FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PCfUUrIY THAT I AM LICENSED UNDER PROVISIONS OF OIAPTER
I (COMMENCING WITH SECTION TOOL) OF DIVISION 7 OF THE B.:S:hCSS AND PROF -F SSIDN S CCCE. AND
MY LICENSE IS N FULL FORCE AND E FFFCT.
LICENSE CLASS �_'�—?/ LIC. NET F'r ` �i •`-�
DATE C� J� CONTRACTOR ; ,
WORKERS' COLOPENSATION DEC RATION
I HCRCOY AiiItA1 UNDER PENALTY Oi' PERA:M CNC OF ME FOLLOWING DCCLAMT
_I HAVE AND WILL MAINTA:N A CERTIFICATE CF CONSENT TO SELF-015UREF NOP'FIT
ODNIPENSA'gN, AS PROV.DCD BY SECTION 7170 OF TIC LABOR
CODE. FOR •E PE IFCRMAN..E
OF THE WORK FOR WHICH 7H'3 PERMIT G ISSUED.
_INANE AND WSLUA' NTA:N WORKEA�CCMPCNSA7CH INSURANCE. AS REGI 'D BY SECT 0.
3f000F DHE LA On COOL. FOR THE PCRFCRMANCE OF THE Won✓. FOR WH:C11 eS PERM:T IS
ISSUED. MY WORKERS'COMPCNSA7TGN; NNSUMNCE CAA'VER AND POLICY M.IMD,T
,I_ "
CAAR:CR
POLICY NUMBER
(THSSECTIONPLEDNOTK/J.OtrM)OrTEPCIRREFCn ONrr ILALW:)Da-' ,LSSxIORLEis;
I CERTIFYT14AT N THE PERFORMANCE OF THE WORK Ton WHICH THIS PEnM:T IS ISSUED, 1
SMALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUlI.ECT TO THE
W7nKERS'COM•'ENSA7ION LAWS OF CALTOFIKIA. AND AGREE THAT IF I SHOULD BCCOMC.
SUBJECT TO INC WORKERS' CCMPENSATIDN Pnoc SIONS OF SECTION 3700 Or THE LABOR
COO ,- L FCnTMt:rH COMPLY W -TM PF%OVISONS
DATE A�1 L APPLICANT.
WARNING FAA UPC TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SMALL BE
SUILIECT AN EMPLOYER TO CR ANAL PENAL1:ES AND CML FNES UP TO CME HUNDRLD 1HOUSAND
DOLLARS (5100.000). IN ADDITION 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 AFFIRM UNDER PENALTY Or PETJURY THAT TIE P.C. IS A CONSTRUCTION LENDING AGENCY
FOR 71-C PERFORMANCE OF THE WORK FOR WTI:Ct THIS PE RM:T 13 ISSUED MSEC. 3007, C:V C.).
LENDCRS NAME
LENCERSADDRCSS
:ccRTIFYTHATIM .E CADTM:SA-PLICAIONAND STATE THAT THE ABONC OJO
OFMATN IS CORRECT.
I AGREE W H ALL CITY AND COUNTY ORDINANCES AND STATE LA's RELATING TO OULDa1G
CONS7P' TIOI.WC I[RCBY AUTMOL'ZE REPRESENTATIVES OF THIS CCUNTY TO ENTER UPON THE
ABOVE 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 SO. FT, FACTOR PSF ADJ. AREAIVALUATION
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QUANTITY DESCRIPTION FEE
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RETENTION FEE'
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TOTAL FEES _ U
COMMENTS
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RCCPT NO._�',a—EJR PAID DY VALIDATION
Mill E --Department CGPy. YELLOW--Fnsnce Copy. PINK—Assessor Copy. GOLDENROD --Fila Copy, GREEN—Applicant's Copy
CITY OFDlAMIOND.BAR
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