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Home My WebLink About17922 (10) �� CITY OF DIAMOND BAR � � DEPARTMENT OF COI�IIviUNTi'Y&DEVELOPIvIENT SERVICES 21825 E.Copiey Drive (909)860-3195 Fax(909)861-3117 PRESS ��»�^ BUILDING PERMIT APPLICATION FIRMLY � JOBSITE /3y� /_^�� /� APPLICATION PERMIT � P/C � ADDRESS_ ��y- « DATE NUMBER # °-° APN LOT T CT ISSUE TYPE OCC � �C�� , DATE CONST. GROUP p OWNER _ �/� i ---- o ADDRESS�-��'�—'"s�-� ZONING S ACKS z CITY /��eR�� ZIP 4/T `. TEL. S J I FRONT Ryy ❑ � APPLICANT TEL. REAR ❑ Z -- SIDE/SIDE STREET RW � QCONTRACTOR_ - �C. SIDE � _ � ADDRESS Z�• �rt�.<< �P � CITY /�./•�L.-ts� ZIP�-�J��"TEL. PROPOSED USE o ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS � CITY _ ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/AD�/REM O p I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS�I� G8ffl98/GBfPOR W CENSEL4WFORTHEFOLLOWINGREASON(SEC.�031.SBUSMESSANDPROFESSIONSCODE:ANVCITYOR (� U COUNTVWHICHREOUIftESAPERMITTOCONSTRl1CT,ALTCR,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC� w TURE,PFIOR 70 ITS 153UANCE,ALSO REQUIRES THE APPIICANT FOR SUCH PEPMIT TO FILE A SIGNED w Pa[io/Deck � STA7EMENT THAT HE OR SHE IS IICENSE�PURSUANT TO�HE PROVISIONS OF THE GONTRACTORS LI- � � CENSE LAW(CMAP7ER 9(GOMMENQNG WITH ScCT10N 700a)OF�NISION 3 OF THE BUSINESS AND PRO� POOVSpfl � FESSIONSCODE)ORTHATHEORSMEISE%EMPTTHEflEFROMANDTHEBASISFORTHEALLEGEDE%EMP- (� U TION.ANYVIOLAT�ONOFSECTION703I.SBVANVAPPLICANTFORAPERMITSU&IECTSThEAPPLICANTTO z Re-Roof � A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED�OLLARS(f500).j: O ❑I,ASOWNEROFTHEPROPERTV,OFMYEMPL�YEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERFD FOR SALE(SEC.]044,BUSI- J � NE55 ANO PROFESSIONS CODE:THE CONTRACTORS LIC[NSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTY WHO 9UILD5 OR IMPROVES THEREON,AN�WHO DOES SIICH WORN HIMSELF OR HERSELF OR � THROUGHNISOflHEROWNEMPLOYEES,PROVIDE�THATSUGHIMPROVEMENTSARENOTINT[NDEDOR m w OFFEREDFORSl�LE.IF,HOWEVERT7IEBUIL�IfvM1GORIMPROVEMENTI550LOWITNINONEVEAROFCOMPLE- � TION,THE OWNER-BUILOER WIIL HAVE THE BUROEN OF PPOVING THAT HE OR SHE�I�NOl dUILD OR z IMPROVE FOR 7HE PUFPOSE OF SALE). �_ ❑I,ASOWNEROFiHEPFOPERN,AME%CLUSNELVCONTRACTINGWITHLICENSE�CONTRACTORS TO CANSTRUCT THE PflQ1ECT(SEC.7004.BUSINESS AN�PflDFES510N5 CODE THE CONTRACTORS LI- V81UeIlIX1 ADJ.AREA W CFNSELAWDOESNOTA7PLVTOANOWNEROFAPROPEHTVWHD9U�L�SORIMPROVESTHEREON,AND � WHOCANTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)L'CENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). � ❑I AM EXEMPT UNDEP SEC. B.&P.C.FOP THIS REASON J � a 7r U � � DATE OWNER U Z W � LICENSED CONTRACTORS DECLARATION w ¢ � I HEREBV AFFIFM UNDER PENALTV OF PEfiJU Y THAT I AM UCENSED UNDEP PROVISIONS OF CHAPTER �Q, �ry d 9�COMMENqNG WITH SECT N]a00)OF DI ION 9 OF THE BUSINESS AND PROFESSIONS CODE,AND Z •' � � -(�' X MY LICENSE IS IN FULL FO AND E FE . �j C� C � UCENSECLASS LIC.NO. • r ` �`�r— j � J V DATE CONTRACTOR_ d W � WO ERS'COI,APENSATION DECLARATION Q � 1 HEREBY qFFIqM UN�ER PENFLTV OF PERJUFV ONE Of THE FOLLOW�NG�E0.ARATIONS: Z z IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSFLF-INSl1REFOFWOHKERS' a 2 Q CAMPENSATION,ASPROVIOEDBVSECTION3]ooOFTHELABORCODE,FORTHEPERFORMANCE U Q 1]Gdil[W6AI�FOR WHICH THIS PEFMIT IS ISSUE�. � W �HAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION Q 37000FTHE LABOR CODE.FORTHE PERFORMANCE OFTHE WORK FOfi WHICH THIS PERMIT IS ISSUED.MY WORKERS'COMPENSAT NS'JRANCE CARRIEfiAND POLICV NUMBER ARE: CONSTRUCTION ¢ CARPoER � �� PLAN REVIEW � ZPOLICV NUMBEH _G /r 7 L� � C� . 7 7 ELECTRIC . a �7�'�=� .�— � (IHISSEC�ICNNEmNOTBECJMPLETE00FhIEPEFiMITISFORONEHIM�RED (5100)IXilE55). PLUMBING ____ Z I CEFTIFV THAT IN T�-1E PERFORMANCE OF THE WORK FOR HIS MI IS ISSUED,I MECHANICAL C.'} SNALL NOT EMPLOY V PERSON IN.>NV MANNER SOAS BECO JE 'O THE � WORNERS'C PEN TIONLAWSOFCALIFORNIA, O L�BECOME INSPECTIONFEE = SVBJECTTO E W RKERS'COMPENSATION PR SEC ON 3] .E LABOR GO�E,I A F ITH COMPLY Y/ITH TNO PRO ISSUANCE � /� � p �ATE� � APPLICANT�. � SMIP J WARNING:FAIL E T ECURE WORNERS'COMPENSATI COVEfiA IS UNLAWFU�,AND SHALL BE ENERGY P/C � � SUBJEGT AN EMPLOV R TO CftIMINAL PENALTIES MI�GIVIL TO ONE MUNDRED TMOUSAND ENERGY PERMIT DOLLARS(51aa oao),IN A��ITION TO THt COST OF COMPENSATION,OAMAGES AS PftOVIDED FOR IN J SECTION3�OBOFTHELABORCODE,INTEREST,ANDATTORNEV'SFEES. flETENTIONFEE' � ' OCONSTRUCTION LENDING AGENCY PPE-ALT FEE: � IHEREBYAFFIRMUNDERPENALTYOFPERJVRVTHATTHEREISAGONSTPUCTIONLENDINGAGENGY _ _ FOR THE PERFORMANGE O(THE WORK FOR WHIGH THIS PERMIT IS ISSVED(SEG.309T,GIV.G.�. Z W = LENDER'S NAME � H LENDER'SADDRESS w TOTAL FEES �� I�� 1 CERTIFV THAT I HAVE REAU THISAiPLICATIONAND STATE THAT THE ABOYE INFORMATION IS CORRECT. � I AGREE 70 COMPL�WITH FLL CITY FNO COUNTV OROINANGES AND STATE LAWS PELATIYG TO BUILDING S � GONSTRUCTION,ANDHER HO EREPRES V SOFTHISCOUNTYTOENTEFUPONTHE Z Af30VE-MENIIONEOPR qTVFO SPeGTION OS � Q COMMENTS � � ____ ¢ PEFMITTEENAME�PRIN C � -2 f� �., � SIGNATURE OF PERMITTEE �ATE = RECPT.NQ PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK�—Assessor Copy,GOLDENR D—File Copy,GREEN—Ap IicanYs Copy � � F � � � �, .�,, �� Hia�� `� � a,. � .vs �� ' ��h�, � �+��' 4�, �' �,�. � �.. :, a= :.,�� '�, ' ; B�:� ..� .� ;,�. �r.. m � ,. . .�• . . , .. . _ , ; �..` `. �. � . ` . , �'� rL,^- �' .r ..�,.,a�'.�c�i�;c _ ' ...... . .. . . .. ... ... .. ... `. un � �- - .... .. .. ` w� tr� ��. � .,� � � . . .... . .. ....... .... ...... ... . . . .... _. ... .. .'. . ... .. . .._.. ... ! � t . ... . . . .. .. .... . . .. ..... .. .._ . .... .. .... .. ... . . �� sis : : 4 .. �� a � a ,� � � . �.� i � � �� .� �r � � ^ �";. ��i�'i�a��id ��, ��` `� �c . . . A�r� i.tr�aa��i��a� ��a .�,„ � {`' � , m ,. . ° � _._ . .._. . .... .. .. ... .. ..... _ . I�, .� �., . _. . . .. . .. _ 7�� ' ^ ; : .��. . . . . ... .. ... . . .. ... ....... . . ...... '.. a �� ° �� i�. � � _ . „ _ , �o, .,,i . : - . CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE ADDRESS 3yL/-�rE%c��/� ADDRESS APN LOT TRACT OWNER�Ili4r ADDRESS��'I�-�"' CITY ZIP TEL S 1 APPLICANT TEL. CONTRACTOR_h . ADDRESS?Z� t� i+lt S- CITY' .61Z its el'ZIP V S TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT.ALTER. IMPROVE, DEMOLISH,OR REPAIR ANY STRUC. TURE,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 LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^I,AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI- 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 HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC. TORS LICENSE LAW.). ^I AM EXEMPT UNDER SEC. B. &PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJU Y THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECT N 7000)OF DI ION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FO AND E FE 77/77 LICENSE CLASS LIC. NO DATE L119V1.4 :T-CONTRACTOR WO ERS'COMPENSATION DECLARATION I 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 3700 OF THE LABOR CODE, FOR THE PERFORMANCE 9P6AI�FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSAT NSU E CARRIER AND POLICY NUMBER ARE: CARRIER ._7 Y POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED($1 00)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR HIS MI IS ISSUED,I SHALL NOT EMPLOY Y PERSON IN ANY MANNER SO AS BECO JE TO THE WORKERS'C PEN TION LAWS OF CALIFORNIA,0 LD BECOME SUBJECT TO E W RKERS'COMPENSATION PR SEC ON 37 E LABOR CODE,I A F ITH COMPLY WITH THO PRO DATE:APPLICANT: WARNING FAIL E T ECURE WORKERS'COMPENSATI COVERA IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOY R TO CRIMINAL PENALTIES AND CIVIL TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097, DIV.C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HER HO E REPRES V S OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PR RN FO SPECTION OS PERMITTEE NAME(PRIN SIGNATURE OF PERMITTEE DATE APPL L ICATION PERMIT ! /C DATE I I , N # UMBER ISSUE TYPE OCC lA DATE CONST. GROUP 1 ZONING SE BACKS FRONT RW ^ REAR F1 SIDE/SIDE STREET RW E] SIDE 7) PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM U) Garage/Carport w Patio/Deck L.I LL Pool/Spa Z Re-Roof Commercial Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U I- U W W Z ^'rY M CL U Z 2 U W CONSTRUCTION V PLAN REVIEW ELECTRIC ! 1 �• PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT N0. 11 N VALIDATION PAID BY WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Ap licant's Copy