HomeMy WebLinkAbout17594 (25) _�� CITY OF DIAMOND BAR �XPBRED
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
Zi�o E.coPiey n,a�e s,��i90 J U N 19 2002
(909)860-3195 Fax(909)861-3117 PRESS
����'� BUILDING PERMIT APPLICATION FVRMLY
� JOBSITE # � APPLICATION ��} �, PERMIT � C�p P/C
� ADDRESS � �� U�rr C DATE I y� ��UMBER I I� #
� ISSUE TYPE OCC
APN LOT iTRACT DATE CONST. GROUP
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CITY ��-fh�Lla r!�1►�.- ZIP�/v2� / � �� PROPOSED USE
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� DESIGNER — NO.DWEL. NO. NO.
a ADDRESS UNITS STORIES BEDROOMS
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N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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0 I HEREBY AFFlRM UHUER PENAITI OF PERNRY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f89B/C81pOfI
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYCINOR (n
CJ COUMVWHICHREWIRESAPERMRTOCONSTRUCT,ALTER.IMPROVE,DEMOIISH,ORREPAIRANYSTRUC- W PdIiO/DBCk
w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED w
� STATEMENT THAT HE OR SHE IS LICENSED PURSUAM TO hiE PROVISIONS OF THE CONTRAC70R5 LI�
c CENSE UW(CHAPTER Y(COMMENCINO WI7H SECTION 7000)OF DIVISION 9 OF THE BUSINESS AND PRO- � POOVSPe
F FESSpNSOODE)ORiHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEOEDEXEMP-
V TION.ANYVqLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSU&IEC757HEAPPLICAN7T0 Z Re-Root
� A CIVIL VENQN OF NOT MORE THAN FIVE HUNDRED DOLUHS(f5o0).): ,
� OI,ASONRIEROFTHEPROPERTY,ORMVEMP�OVEESWITHWAGESASTHEIRSOLECOMPEN5A710N, � COfflfn0fCl81 "
WILL DO THE WORK,AND THE STRUC7URE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70N,BUSI� J
� NESS AND PqOFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
VROPERTY WFiO BUILDS OR IMPROVES THEREON,M1D NMO DOES SUCH WORK HIMSELF OR HERSELF OR
� TMROUGH HIS OH HER OWN EMPLOVEES,PROVIDED hiAT SUpI IMPROVEMENTS ARE NO71N7ENDED OR m
QOFFEREDFORSALEIF,HOWEVER7NEBUILDINGORIMPROVEAIENTISSOLDWRHINONEVEAROFCOMPLE-
Z �TqN,THE OWNERAUILDER WILL HAVE 7HE BURDEN OF PROVING THA7 HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PUHPOSE OF SALE).
❑I,tiS OWNER OF THE PROPEHTY,AM EXCLUSIVELY CONTRACTINO WfTH LICENSED CONTRACTORS
Q TO CONSTRUCT THE PRO,IECT(SEC.7os1,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI� V81U8l1Of1 ADJ.AREA
W CENSE UW DOES NOTAPPLY TO AN OWNER OFA PROPEH7V WHO BUILDS OR IMPROVES THEREON,AN0
� NTiOCONTRACTSFORSUCHPR0.IECTSWITHACONTMCTOR(S)UCENSEDPURSUANTTOTHECONTMP pUANTITY DESCRIPTION FEE �
Y 70R.L1cEN5E Uw.).
� O I AM EXEMPT UNDER SEC. 8.6 P.C.FOR THIS REASON U
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DATE OWNER V
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F LICENSED CONTRACTORS DECLARATION w
, � I HEREBY AFFIRM UNOEP PENALTV OF PERJURV THAT 1 AM LICENSED UN�ER PHOVISIONS OF CHAPTER � � p�
� 0(COAIMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE,AND Z �-��
�� MY LICENSE IS IN fUL FORCE AND EFFECT. m
� UCENSE CLASS ✓`� LIC.NO. ��yJ�J �
V DATE � �� L�"'—� CONTMCTOR �' a
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� WORKEAS'COMPENSATION DECLARATION a
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� I HEREBY AFFlRM UNDER PENALTV OF PERIURV ONE OF THE fOLLOWING DECLAMTIONS:
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� _1 HAVE ANO WILL MAINTNN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR VK7RKERS' 2
COMPEHSATION,AS PROVIDED BY SECTION 370o OF THE LABOR CA�E.fOR THE PERFORMANCE U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
�
_I HAVE AlID WILL MAIMAIN WORNERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 37000F TNE LABOR CODE,FOR THE PENFORMANCE OF THE WORK FOR WHICH THIS PERMI715
ISSUEO.MY N'O KERS'C`OM�P,ENSATION INSURAN E CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
� CARRtER S�1'�. FU��a PLAN REVIEW
� POLICV NUMBER �I,h'�D ' �o ELECTRIC I 1
� (iHISSECfICNNE�NOTBE001.WLE1IDOF71EPERMT6inROMEHlRd7PEDDOLLARSK��)�LFSS� PLUMBING
w MECHANICAL
Z I CERTIFY THAT IN TME PERFOiiMANCE OF THE M/0RK FOR WHICH THIS PERMIT IS ISSUED,I
(} SHiLL1 NOT EMPLOY ANY PERSON IN ANY MANNEq 50 n5 TO BECAME SUBJECT TO THE
� WORKEHS'COMPENSATION LAWS OF CAI.IFORNIti AND�GREE THAT IF I SHOULD BECOME INSPECTION FEE
S SUBJECT TO THE WORNEHS'COM7ENSA710N PHOVISIONS OF SECTION 3700 OF THE IABOR �'���'�l
CODE,I SHALL FORTHWITH COMPLV WI THOSE PROVI 1pNs. ISSUANCE '` �
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p DATE: ^� G� �qPPLICANT: � �SMIP
w ENEAGY P/C
J WARNING FAILURE TO SECURE M/ORKERS'COMPENSA710N COVERAGE IS UNUWFUL,AND SHALL BE
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AN�CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOIURS(ita0,00o).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 370!OF T1E LABOR OODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � �
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d CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
CL I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUC710N LENDING AGENCY
d FOR THE PERFORMANCE OF 7HE WORK FOR WHICH 1HI5 PERMIT IS ISSUED(SEC.3007,CIV.C.). �
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� LENDER'S NAME
1_ IENDER'SADDHE55
� ICERTIFYTHATIHAVEREADTHISAPPLICATIONM'DSTA7E7HATTMEABOVEINfORMATqNISCARRECT, TOTAL FEES `1 �
w I AGREE 70 COMPLV WITH ALL CIT'AND COUNTY ORDINANCES ANO STATE UWS HEUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHOfiRE RE7RESEN7ATIVES OF 7HI5 COUNTY TO EMER UPON THE �
Z /�BOVE-MENTIONED V R1V FOR INSPECTION OSES. COMMENTS
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m PERMITTEE NAME(PRINn ���
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y SIGNATUREOFPERMITTEE DATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE-0epaAment Copy,YELLOW�inence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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