HomeMy WebLinkAbout14964 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
1 BUILDING PERNIIT APPLICATION FIRMLY
JOBSITE
ADDRESS 7 D1'C. -
APN LOT TRACT
OWNER
ADDRESS
CITY 2/.�70f1rfi lm ZIP TEL d /— L
APPLICANT TEL.
CONTRACT R Liv
ADDRESS / T.,
CITY W ZIP TEL O - S
ARCHUENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAN' FOR THE FOLLOWING REASON (SEC. 7071-7 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTYWHICH REOUIRESAPERMRTO CONSTRUCT,ALTER, IMPROVE, DEMOLISH, OR REPARANYSTRUC
LURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
DENSE LAW (CHAPTER s (COMMENCING WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PRO.
FESWONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TtON.ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
AN` PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSOO).):
O L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WOW, AND THE STRUCNRE 15 NOT INTENDED OR OFFERED FOR ME (SEC. 70IM, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTYWHO SUMS OR IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELFOR
THROUGH HIS OR HER OWN EMPLOYEES, PRDVIDEDTHAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPL6
TION, THE OWNERSI)LDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY. ALI EXCLUSIVELY CONTRACTING WITH LICENSED COMAACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LG
CENSE LAW DOES NOTAPPLY TORN OWNER OF A PROPERTY WHO BUMS OR IMPROVES THEREON, AND
MAOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE OONTRAC•
TORS LICENSE LAW.H.
O 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASCN
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFRFIM MINDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
B(NCWRNSECTIDN7000)OFOMSION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
MY MENO
ENBE IS N FULL FORRCCE AND EFFECT.
E CLAAS'SCts LIC. NO.
• /6,T O CONTRACTOR < 1
<r L.KJRL�1
WORKERS'COMPENSATIONDECLARATION FAD
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 77DO OF THE LABOR CODE, FOR THE PERFORMANCE
E WORK FOR WHICH THIS PERMIT S ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' OOMPENSATION INSURANCE, AS REWIRED BY SECTION
77 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
IS ED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
FIER N % 1~r—ec,
ICY NUMBEFINLy -2f: 7,106 S
Cn4SSEMMN®NOTSEOCLIRLETEDOFTHEPEPMTSFORONEHADFIEDDM AR6R100)ORLESS}
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT S ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PRONSIONS OF SECTION 7700 OF THE LABOR
/SHALL RTHWITI COMP LY WITH THOSE PROWS IONS.
DATE: / O APPLICANT:'_,
WARNING: FAILURE TO SECURE WORKERS' CQSP OVERAGE IS UNLAWFUL., AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (6
1 0
0,DDOL N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 7700 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 13 A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 70.7, CIV C.),
LENDERS NAME
LENOERSADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
VVFII I L-tiJepartment Copy, YELL0VY--F1n0nOB COPi, PINI
APPLICATION
/� GD PERMIT f �Q� P/C
DATE jr NUMB f 1(
7,ISSUE TYPE OCC
DATE�CONST-
GROUP
ZONING SETBACKS
FRONT RW p
REAR p
SIDEISIDE STREET RW ❑
SIDE p
PROPOSED USE �L
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION Sa. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADDMEM
Garagwr rport
WPatio/Deck
LL
PoGUSpa
Re -Roof
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
ccU
F
U
W
L9
Z
m
a
U
i0 C�-
Z
I z,0
UI
MCJb 440
C
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUbdRIN
!Mo ECHANI 41—
FEE
ISSUANCE
ENERGY P/C '
ENERGY PERMIT A
RETENTION FEE:
PRE -ALT FEE: —^v3Ku
V3/
Y
TOTAL FEES 7
COMMENTS
RECPT NO. PAID BY VALIDATION
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