HomeMy WebLinkAbout15126 (20)CITY OF DIAMOND BAR
DEPART14ENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOSSITE
ADDRESS�Q oRTO C12RJvG� Z
APN LOT TRACT
OWNER
ADDRESSamon
CITY 1 ZIP j TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCR'ENG1
DESIGNER
ADDRESS
CITY ZIP TEL.
OY.TIER-BUILDER DECLARATION
I HCREBY AFFIRM UNDER PENALTY OF PrR 1JPY TNAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWNG REASON (BEC. 7001.S OUS.NESS A%D PRDrEss ow CODE ANY CITY On
COUNTY WHiC H REQUIRES A PEPMTT TO CONSTRUCT, ALTER IMPROVE. DCMOUSIL CR RE PA011LNY STRUC-
TURE, ►ROR TO ITS
ISSUANCE, ALSO RECU:RCS THE APPLICANT FOR SUCH PERM T TO FILE A S:G.NED
STATEMENT THAT HE On SHE IS LICENSED PURSUANT TO THE PROVLS ONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER a SHE
WITH SECTION 700C) OF DNISON S OF THE B'vviESS AND Pn0-
FESSOA: NS000E)OR THAT. HE ORSHE IS EXEMPT THEREFROM ANDTHC BASIS FOR THE ALLEGED EXEMP-
TION
XEMP-
O
TN ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PEAMI 7 S: SECTS THE APPLICANT TO
A C1VL PENALTY OF NOT MORE THAN FIVE HL.WDnrD DOLLARS ({SOLI P
❑ L AS cmEn Or THE PROPERTY, On MY EMPLOYEES WITH WAGES AS THE.R SOLE COMPENSATION.
AN
WILL DO THE WOW. O THE STRJNDED
CTURE IS NOT INTEED OR OFFERFOR SALE (SEC. 7044. BUSI-
NESS AND PFOFES5K)NS CODE, THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PRDPEI .Y
"to BULOS OR IMPIOVES THEREON. AND W D DOES SUCH YORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER CA" EMPLOYEES. PROY.CED THAT SUCH IMPROVE MENTS ARE NOT INTENDED OR
OFFEREDFOR SALE G,NOWEVERTIE DULDING OR YPIIO'V[urNT IS SOLD WTH1401.EYFA7 OFCOM' '
TON, THE OWNCnSIALDER WILL FIAVE THC BUnDrN OF PROVING THAT HE OR SHE DO NOT BD:LD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTNO W::H LICENSED cowMCTORS
TM
TO CONSTRUCT C PROJECT (SEG 7944. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TOAN OWNER OF A PROPERTY WwO BULDS OR IMPROVES THEREON. AND
MAID CONTRACTS FOn S'JCH PFIOJCCTS WITHA CONTRACTORIS) LICE`. SED PUnSUANT TO 714E CONTRAC-
TORS LICENSE LAIN).
O IAM EXEMPT UNDER SEC. B LPC FCR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIPAT uNDCR PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
B(OOMMENC'NOWITH SECTION 700C) Or DIVISION a Or THE BUSINESS AND PROF SESSIONS SSIONS GAND
MY LICENSE 6 N iUJ. r0 ^C FCCi.�"
LICEN°ECUS. LIC. 449
DATE a CCNTFLA=on
WORKERS' COMPENSATION DECLAFIATIOY
1 HERERY AFFBW LNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
1 HAVE/ND WSL MANTNN A CERTIFICATE OF OONSENT TO SELF-INSUnE FOI WOIIKERS
rr'CO TH NSIITON, AS PROVIDED BY SECTION 7700 CF THE LADOR COCE. FOR THE PERFORMANCE
THE WORT( FOR W11101 TH:S PERMIT IS. ISSUED.
I HAVE AND W LL LIANTAIN WORK RS' OOMPENSATKO4 INSURANCE, AS RCCIATIED BY SE CTKNi
.700 OF THE LABOR CODE, FOR THE PE RFORMANCE OF THE WOPK FOR WH:CN1 THIS PERMIT IS
MSUED. MY WO,IKEP^' COMPENSATION INS:.YtANC[ I..Y�O CYN' aFR AFIC
cAnn:En _
POLICY NUMBER
fDcssccr10NtiT.EDNO:000O -i:EDOFTLFS7MTISFORONLH11LrL'D LARSia"JL)ORLLSS)
1 CEnTSY DOT N THE PCRrorwANCE Or THE WORK ron WHICH THIS PERUIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNCFI SO AS TO BECOME SUMECT IO TIIE
WORKERS' COMPLNSATON LAWS OF CALIFORNIAAND AGREE TI -Ar IF 1 SNOLLO BECOME
SIA..TfTTO TH WORKER; COM°E PRDY'15KONS OFSEI:TON77000r THEL ^On
COD /7///I SMALL �H1MTH COMPLY W H M�. °qDW SON`
DATE. � APPLICANT.
WAntr G ALUs TOSECVFIE WORKERS'COMPENSATON COVERAGE 15 UNLAWFLi,ANO SILLL BE
<'UILIEGT AN EMPLOYER TO CRIMINAL PENALTIES AND CML F h -.S UP TOONE HVPORLD TIOUSAND
DOLLARS IS 100.000). N ADDITION TO THE COST OF COMPENSArON. DAMAGES AS PROVIDED FOR IN
SECTION 370S or TIE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM LNOCn PENALTY Cr PERJURY THAT THERE IS A CONSTRUCTION LENOWS AGENCY
FOR THE PEOroOMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3C.97. CIV C.).
LENDERS NAME
LENOERSADDnESS
I CERTIry THATIHAVE RFA7 THIS APPUCA:'ON 0STA'.EnuTn1E AD0VE NFOFWATONIS CORTCCT.
I
AS CE TO COMPLY WTTHALLCITYAND GOUh ORDINANCES AND STATE LA'S RELATING TODULDING
CONSTRUCTION, AND HCREBYAUTHOni2E REPI SENTATNES OF THIS COUNTY TO ENTER UPON THE
ADOVE MEHTI�OMD PROPERTY F R INSPECT FL'R"s
IN
PERM 1 NT) — —
SK:NAIUPL' G P iWI71L 0
PRESS
FIRMLY
APPLICATION f I ERMIT /C
DATE -UMBER l NUMBER N
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDESTREET RW ❑
SIDE p
PROPOSED USE
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ.AREAIVALUATION
SFRlADD.nEM
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W
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Va'ua!icn ADTAREA
OUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
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MECHANICAL r T >
INSPECTION FEE y
ISS ANCE �° V
JUN
SMIP JUN �r %Ilii I
ENERGY PIC
ENCRGYPERA!IT
RETENTION FEET: • `t •, _.....1 — 1 1
PRE -ALT FEE:
TOTAL FEES 31
co ENrs
=ETU
RECPT. NO. PAID BY VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Ccpy. GOLDENROD—FIk7 Copy, GREEN—Apglcant's Copy
CITY OF DIAM101M BAR
INISPECTION'RECORD
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