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HomeMy WebLinkAbout15074CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909)860-3193 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE ^' j` ``II 4 N y ADDRESS 2& 1 APN LOT TRA T OWNER ADDRE G IN CITY ZIP TEL, APPLICANT TEL CONTRACTOR ADDREidi CITY ZIP TEL ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE OOM7IACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSINESSAND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH REOURESA PERMRTOOONSTRUCT,ALTEFi IMPROVE, DEMOUSH, OR REPAIRANY STRUC. TURF, PRIOR 70 ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO RLE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE LANA (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND Pim FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMR TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACRAL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): O LAS OWNER OF THE PROPERTY. OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, SILL OO THE WORK. AND THE STRICTURE IS NOT MRENDEO OR OFFERED FOR SALE (SEC. 7044. BUS4 NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR THROLIM FSS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFEREDFORBALF IFMIOWEVER,THEBULDINGORIWROVEMENTISSOLDWITHINONEYEAROFOOMR.E- TKK THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O L AS OWMEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEG 704. BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS U,- CENSE 4CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOI(S) LICENSED PURSUANTTOTHE OCNTRAC- TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC. B. S PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER SYLICENSE WITH SECTION 7000)OFDIWSMSN SOF THE BUSINESS AND PROFES� SIGNS CODE SND MY LICENSE IS (COMMENCING RAL FORCE AND EFFECT 1 LICENSE S 77 LIC. NO. DATE,90__o2­2jPV CONTRACTOR CAW WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CER ARCATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 1700 OF THE LABOR CODE. FOR THE PERFORMANCE OfiT11E WORK FOR WHICH THIS PERMIT IB ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR OWE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPE'NSAT INS17 rCARRIER D POL MBERARE: CARRIER / C.i! 7r1 2 POLICY NUMBER (RISIJCCTDNFE®NOTBECOAfi.SMOFTEM9FA TISRORONEHNAMDCtJAFIS(;1W)ORLESS), I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'igfl�� ORHA,AND AOREF TENT IF 1SHOKO BECOMESUBJE TVISKINS OF SECTION 5700 OF E IASORCODE, TH E DIVISIONS.DATE: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100.6N), IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 5700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THATTHERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 5047, CIV. G). LENDERS NAME LENDER'SADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STA THAT THE ABOVE INFORMATION IS CORRECT. (AGREE TO COMPLY WITH ALL CITY AND COUNTY ORD CES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBYAUTFORIZE REP�PUOSE S OFTHIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR )PECTK� . r� PERME (PRINT) SKMATUP O PERMrtTEE Dire, WHITE—Department Copy, YELLOW—Finance Copy, PINK-- Asse5sm Copy, GOLDENROD–file Copy, GREEN—Applicanrs Copy PRESS FIRMLY APPLICATION/� p► PERMIT �o PIC DATE �L.� NUMBS • ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEMIDE STREET RW ❑ SIDE p PROPOSED USE 1 NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFRIADDIREM 0 Garaga/Carport U.1 Patio/Deck U, POOIISPa ZRe-ROof J Commerclal LU Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U LU W r9 Z MAw m Q U Z Q U w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING f MECHANICAL INSPECTION FEE ISSUANCE ll: , SMIP ENERGY PIC ENERGY PERMIT juilil RETENTION FEE: )1IL11nL L E PRE•ALTFEE: TOTAL FEES c�7 CO TS RECPT. NO. PAID BY VALIDATION