HomeMy WebLinkAbout10742 (5)CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861.3117
BUILDING PERMIT APPLICATION
JITE
ADDRESS./ A/. PIA71R 41 o D r.
APN LOT TRACT
OWNER PTI S
ADDRESS 0
CITY D. ZIP9170C'_ TEL.$L/-777
APPLICANT 641Y&OL TEL.5sbsle
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CIN ZIP TEL.
OWNER•BVILDER DECLARATION
I I.EREBY AFFIRM UNDER PENALTY OF PERA)nY THAT I AM EXEMPT FROM THC CONTRACTORS LI
CENSC LAW FDR TME FOLLCWNG REASON IS CC. 7071.5 BUSINESS ANO PMFESSIONS COC[ ANYCJTY OR
COUNTY WHICH REOARES A PERMIT TO CONSTRUCT, ALTER IMPROVE. DEMOLISH. OR nEPA:R ANY STnUC.
TORE. PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUQI PEM4T TO FILE A SIGNED
STATEMENT THAT NF OR SHE L LICENSED PURSUANT TO THE PROVISI.NS OF THE CONTRACTORS LN
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLE GE.O E%EMP.
TION. ANY VIOLATION OF SECTION 7071 S BY ANYAPPLICANT FOR A PERMIT SUBRCTS INC. ATPOCX47 TO
A CK.L PEI:ALTY OF NOT MORE TITAN FIVEM:NDRCD DOLLARS ({5001 )
LAS OWN ER OF THE PROPCR'Y OR MY EMPLOYECS WITH WAGES AS TMEIn SOLE COMPENSATION.
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SATE (SEC 70AA, B:lSI-
NESS AND PROFCSSIONS OTC. THE CONTRACTORS LICENSEE LAW DOES NOT APPLY TO AN OWNER Or
PROPERTY VA.0 BUILDS On IMPROVES THEREON. AND YARD DOES SUCH WORK HIMSE LF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOY ECS. PROVCED THAT SUCH IMPROVEMENTS ARE NOT N'E MDED OR
OFFERED FOR SALE. W. HOWEVER THE BUILDING OR IMPROVCMCNT IS SOLO WITH40NE YEAR OF COMPILE.
7ION, THE OWNER-BU!LDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT 6UYD on
IMPROVE FOR THE PURPOSE OF 3ALEL
CI LASOWNER or THC PROPERTY, AM EXCLUSIVELY CONTRACTING Vr.TH LICENSED CONTRACTORS
TO CDNSTRUCT THE PROJECT (SEC. 7344, B'JS'NESS AND PROFESSIONS CODE THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY 70AN OWNER OF A PROPERTY MK) BUILDS OR IMPRCVCS THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WI TH A CONTRACTONS)LOAN
ENSCD PURSUANT TO THE CONTRAC-
TORS LICENSE LAW).
O 11AAM EXEMPT UNDER SEC. 8 L PC. FOR THIS REASON
DATE _/ �! 6"9 % OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PCrW M THAT IAM LICENSED UNOE R PROVISIONS OF CHAPTER
9 ECOMMENCNO WITH SECTION 70001 OF DIVISION 3 O THE BUSINESSAND PROFESSIONS CODE. AND
MY LICENSE 13 N FULL FORCC AND EFFCCT.
LICENSE CUSS LIC. NO
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DCCLARA'IONS
I PAVE AND WILL LAXNTAN A CCRTIFICA7E OF CONSENT TO SELF -a SURC FOR WORKERS'
COMPENSAT.ION.AS PROVIDED BY SECTION 37000F THE LABOR ODGE. FOR THE PCRrORMANCE
OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED
_I HAVE AND W'IL MANTA:N WORKERS' COMPEN3ATON!NSURANCE-AS RCOLARED BY SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE Or THE WORK FOR WMCH Tits PERMIT 13
ISSUED. MY WORKCRS' COM?ENSA' ION NSURA).CE CARRIER AND POLICY NL1JBCn ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NECD NOT EE CDI P ETED OF TIC PCMB C FORT ONE FUZMD DCL1hiS IICC)OR LESSL
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WIOCII THIS PERMIT IS ISSUED. I
SMALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BCOOIC SUBJECT TO THE.
WORKER:' COMPENSATION LAWS OF CALBORN A ANT) AGREE THA r IF 1 SHC)ULD BECOME
SUE1JECT TO THE WOnKERS OOMPENSATION PROVISIONS OF SECTION 3700 Cr THE LABOR
CODE, I SMALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS L'FLAWTU. AND SKALL BE
SUBJECT AN EMPLOYE R TO CnIMNAL PENALTIES AND OYIL FMCS UP TO OAC HUNDRED THOUSAND
DOLLARS (111100.OD0). N AODITION TO THE COST OF COMPENSA'10k DAMAGES AS PROV'DED FOR N
3ECTON 3701 OF THE LABOR CODE, INTERESXANDATTORKEY'S FEES
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY Or Pe'RIUnY THA' INC RE IS A CONSTRUCTION LE431I3 AGENCY
FOR INC PERFORMANCE OF THE WORK FOR WHICH THIS PERM:T IS ISSUED (SEC. 3097, CIV C.).
LENDER'S NAME
LENDCFFSADORESS
1 CERTIFY THAT I ILA'.O
'[ READ THIS APPLOATNAND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY OnDWANCCS AND STATE LA:NS ROLA'. NG TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE RCPRESCNTATIVES OF THIS CO(AITY TO ENTER UPON THE
AROVC MENTIONED PROPERTYFOR INSPECTION PURPOSES
' /�,�� J � ccure•!s
PERMITTEE
=2�
SIGNATURE OF PERIATTEE CATE
PRESS
FIRMLY
APPLICATION L �� � IERMIT r
V
DATE- NUMBER M
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE Y&MO L CV,20d S411-014 '
c�elAccF. G[acs SSI n� c
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFFVADD,TIEM
cn
Garatla'Camart
LL1J
Patio.'Deck
LL-
Poo'.'Spa
IrRE.41-'rc
Commercial
m
Valuali Q0A ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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LU
0
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CL
CL
4
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2
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMB.NG z!,
MECHANICAL
INSPECTION FEE
ISSUANCE'
SMIP tJ rl�
ENERGY RIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES +
COMMENTS
�J�J (;
RECPT. NO. PAID BY VALIDAT
WHITE—Department Copy. YELLOW—Finance Copy. PINK—Assessor Copy, GOLDENROD—File Ccpy, GREEN—Applkanrs Copy
CITY. OF DIJ*►ftiMND BAR.'
INSPECTION RECORD
I►`t-�l:a=.c;�'1�,1►�P �.VC= # I�`E=S:J.��'�`�lc�' I,�`F=i���c;�� (cj►�i .i�.Lr= 1►��;�c'�c'•e..,l:.
SETBACK ! I � � FL:>:) ? .I, ;IST I ;
FTGSrFOR :".S;STEEL I i i I 1-11A REC.'.:I`; -- -
ELECTRIC GROUNDI : UNDER FLOOR DUM' ,I;— �,: :_i:�r-• •__� �; _�^'
-----
GROUND P1.0IM, 81IN, G 1 ':. UIJDi_R FV0011CONDUIT
SLAB GRADE I I FIiIFF'Lf,Cr= FOUNDATION - ---- . ( -
-TEMP PO'::Er{ FIREPLACE Ei7iJD BEA.•:.- - - --- - - - - --- - - - ---
WATER SERVICE NT. E30"J7 BEM.l
ROOFSHEATH�NG 1'C_Z.1%r'� = —._ ----'• i'i. Ii'�;J7 f3EAI.1- --- - - --
FRAI'.11iJG!VENTILIATION' l — ! FINIM.
rn"J7 f3^J1i' f -
— -- — -
ROOFCOVER �� ; E CaI;ADING
- —
ROUGH IIEATIN { ;
ROUGH EL.ECTRI,^, I - - - FU C,! I GRADING
FiOUGIi PLUI.131NG FIN:SI I GRADIIJG-
SI10v"JER,TUBTEST -- --� POOL ELEGIRIC-----
EXT. ILATIL'SIDINIG Poch. rENUNG I .
WALL INSULATION [ I I ; POOL FlINIA .
CEILING INSULATIONI i I O� I SITE IMPS. !
DRYWALL NAILING
SEWER E_-_^er.
_; C-
-sIG- .SEPTIC TANK bn,
-
SEEP PITJL.L. I -�__- ON' SITE II"PS. I I
GAS f,IR TEST. .. IIy� I I I „ ZOir'.i•:G ----..-_.....--�- ----•- - ----•--------. --
FINAL CONST. all _ ! /- L _ _ ! FIR!__-DEPT.'FIi:�.L
FINAL HEATINGE_!Ef•.LIEIDEPT. FINAL !--_-._.—.---
FINAL ELECTRIC; I I D::V. f FEES PIAI l - I - - -- - --- -- ---
FINAL PLUS.IDI :G I ENIERGY _ —
I
COAAMENTS --- -- --- - - -- -- -- '
SEPTIC TAIJIC SIZE
SEEP PIT/U SIZE..--
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