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