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HomeMy WebLinkAbout14909 (17)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES ®r 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS S APN OT TRACT OWNER r ADDRESS s/911i CITY ZIP J TEL. APPLICANT TEL. CONTRACTOR L° ADDRESS CITY /i7+ r ZIP SAEV_f_ TEL. Z1 -�_ ARCFVENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-6UILDEn DECLARATION 1 HEREBY AFFIRM UPERJURY NDER PENALTY Or PERRY THAT I AM EXEMPT FROM TIE CONTRACTORS LH CENSE LAW FOR THE FOLLOWING REASON (SEC. 73315 BJS:4ESS AMD PROF ESSKONS COC[. ANY C:TYOR COUNTY YN1CH RCOUIRCS A PEriM:T TO CONSTRUCT. ALTER M°ROVE. DCMOLIS{ On RE PAR AN'Y STRUC. TURF. PRIOR TO ITS ISSUANCE. ALSO RECIARES THE APPLICANT FOR SUCH PCRM:T TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTONSS U. CENSE UW (CO ICHAPTER S MMNWITH TH SECTION 7000) OF DIVISION 7 Or THE BJS-NESS AND ORD. IONS CODE FESS) OR THAT HE Cn SIE IS EX[MRT THEREFROM AND THE BASIS FOR T•E ALLEGED EXEMP' TION. ANY VIOLA' OF SCCTION 7771.5 BYANY APPLICANT FOR A PCnM'T SUrUCCTS THE APPLICANT TO A CrAL PENALTY Or NOT MORE THAN FNE HUNOnED DOLLARS (F70CI } O L AS OWNEn OF THE PROPERTY.On MY EMPLOYEES WI: H WAGES AS THEN SOLE COMPENSATION, WILL DO THE WORK AND TIE STRUCTURE IS NOT IN -ENDED OR OFFERED FOR SALE ISEC. 7:41, BJSb NESS AND PROrESSIONS CODE. THE CONTRACTORS UCCFISC LAW DOCS NOT APPLY 70 AN OWNER O PROPERTY VA40 BUILDS On IMPROVES THEREON. AND W40 DOCS SUCH WOrIK H'MSrLF OR FIC RSELF On THROUGH HIS Dn FIER OWN EMPLOYEES. PROVIDED THAT SUCH PAPAOVCLI[NTS ARC NOT NTENnrD on OFFERED FORSALE Ir. HOWMR THE BUILDING OR IMPROVELIMT ISSOLD WTH:N ONE. YEAR OF ODM :E. TION, THE OWNER41UILDER WILL HAVE THE BJRCEN OF PnOVA0 THA7 HE OR SHE DO NOT DU:LD OR IMPROVE FOR THE PURPOSE OF SALE), O L A. OWNEROFTHE PROPERTY, AM EX LUS:VELYCOHTRACTNI YATI LICENSED CDNTRACTOnS TO CONSTRUCT OHC PnCUrCT (SEC. 701111. BUSINESS AND PROFESSIONS CODE THC CONTRACTORS U• CENSE LAW DOCS NOT APPLY TO A4 OWNER OF A PnOPCnTY WHO BUILDS OR IMPRCVE S THEREON. AND WHO CONTRACTS FOR SUCH PROTECTS VRTHACONTRACTOn;S) LICENSED PUnS.M1 T TO THE CONTRAC. TORS LICENSE LAW). O I AM EXEMPT UNDER SEC B APC FCR DIM REASON DATE OWNER LICENSED CONTFIACTOAS DECLAnATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED U ,ER PROVISONS OF D APTER ■ (COLMENCING W.TH SECTION IWC) OF CM.SION 7 OF THE BUS NE SS ANO PROFESSIONS COO[. AND MY LICENSE IS N FULL FORCE AND EFFFF+ECT. LICENSECLASS �(�(�/ LIC. NO. _ DATE ti:: e12C CONTRACTOR__ WORKERS' COMPENSATION DECLARATION 1 HCRCBYAFBVA UNDER PENALTY Or PERJURY ONC OF THE FOLLOW -NG CECLARATOINS. _I HAVE A40 WLL MANTA:N A CE W..IricATC OF CONSENT TO SELFJN'SURE FOR WORKEFi S' CNSATgN. A, PFIIMD[D BY SEcT)oN 7700 or THE LADOn CGDE. FOn TINE PERrOnMANCE THE WCRtlU FOR WIHICH TH:S PrnMIT IS ISSUED. I HAVE AND WILL MA:NTAN WORKERS' COMPCNSAMN INSURANCE, AS REM:RED BY SECTILW 7700 OF THE L/1fiOF1 OODr.. OR lE P"E;pANCE Or THE WORK FOR W4'CH THIS PERM'T IS ISS:IED. MY WORICn^' PE. ATXHJ/IIS^�'Y'�A4CC RR:[R AND POLICY MJMUER ARi CARRIER • — POLICY NUITO[R,� %�Y me SrcncN NETT. NOT AC COMIU7E0OrTC PES IS FOA DNE R N1REDDUlAR s 3lx: on LESS) I CEnTIFY THAT N THE PEnronmANC[ OF THE WORK Fon WITCH TH•S PEPMIT IS ISSUED. I & AU NOT EMPLOY ANY PERSON N ANY MA.NNEn SO AS TO BECOME SUBJECT TO TIE WORK COMPCNSAT ION LAWS OF CALIFORNIA AND AGREE THAT IF 1 S C SUB:CCT TO THE WORKERS' COMPENSATION PnONS10N5 OF SEC'.I iA 01 T R COOT. 1 SHALL FOnTHW1THCOMPLY V61714 DIME P/R/�7OOV...SS)ISO/7NNr DATE: �y= APPLICANT.---R%Sl: A — — WARNING FA'LURETOSECUREWOrtKCn�CC4HPE Hh COV'ERAGr ISU'IaAM1,LSHA; .A L BE. SL,WECTA.N EMPLOYER TO CRIMINAL PENALTIES AND CN'L FINES UP TO ONE NLIN.'O11F' iFwSAND DOLLARS (7100.0001. LN ADDITION TO THE COST Or GOAPCNSATION. DAMAGES AS PF.OV.7ED Folk IN IO SECTN 77011 OF THE LAROn COOL. IHTEPEST, AND ArTOrLNCYS FEES. CONSTRUCTION LENDING AGENCY 1 HERE BY AFF:nM UNDER PENALTY Or PEFUUnY THAT THERE IS A CONSTRUCTION LENDINo AGENCY FOR THC PE RFORMANCE OF THE WORK ron W 4CHH THIS PERM:T IS ISSJLD (SEC. 3 PI, CIV C.). LENDERS NAME LENDERS ADDPESS 1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE NronuxT10N is CORRECT. I AGREE TO COMPLY WITH ALL CRY AND GOLNTY 0110 NAYCES AND STATE LAWS RELATING TO BU:LDING CONSTRUCTION. AND HEREBY AUTHORIZE RLPRF SFNTATIYES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPER IN SPE '10N PL;IUPOSCS PER IEl (PP' I S+GryIU F MEE SDA:L r PRESS FIRMLY APPLICATION PERMIT IJ P/C v DATE NUMBER i p - ISSUE��TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR p SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFFVADD,'nEM Ga•agR'Carpert WPa;IC/Dock LL POO:'Spa 0 Z n0-RDot 0 Co ercia! 'a'uatbn ADJ.ARCA OUANTI DESCnIPT10N J Q U F— U w J W Z _ J b l 7 a a U Q x U w 1 CONSTRUCTION PLAN REVIEW ELECTRIC PLUMDING MCC)IAN:CAL INSPECTION FEE ISSUANCE 'U SMTP ENERGY P,'C ENERGY PERMIT RETENTION FEC: PRC -ALT FCC: 1 TOTAL FEES COMMENTS if � nECP�� _PAID 6Y VALIDATION E--Wartment Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—Filo Copy, GRCCN—Applicant's Copy