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HomeMy WebLinkAbout14974 (19)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES d 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 »� BUELDING PERMIT APPLICATION JOBSITE ADDRESS 7lJ \\'L(,l.'1✓ C LWO APN LOT TRACT OWNER ADDRESS a CITY ZIP TEL. k-9br APPLICANT TEL. CONTRACTORPC'7S� 1c �Ci �S ids i �S ADDRESS Sia 3 ?LACZSt�"y CITY Lao�ZIP 1-ATEL. 3";*T +TLt.�- 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- CENSELAW FORTHE FOLLOWING REASON (SEC. 70315 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANYSTRLC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMITTO FILE A SIGNED STATEMENT THAT HE OR SHE 15 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 OODE) OR THAT HE OR SHE 13 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 70315 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (i S00I.): 01, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED On OFFERED FOR SALE (SEC, 7011, 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 ISSOLD WITHIN ONE YEAR OFCOMPLE- TION, THE OWNE"UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ED I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70". BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILOS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A OONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ❑ I AM EXEMPT UNDER SEC. B. K P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. �f LICENSE CLASS , aG-LIC. NO. DATE Ii'� CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY -OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BYSECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. MY WORKERS' SCOMPENSATION �NSU RANCE CARRIER AND POLICY NUMBER ARE: CARRIER 1 •'f.T^�Ac'�+ .moi-:�..J�f.-,.",y, �- L(aA`T/�' POLICYNUMBER _�(,�.is�5.� (THIS SECTION NEEDNOTBE COMPLEfEO OFTHE PERAYT IS FOR ONE HUNDREDDOL ARS ($i O0) OR LESS). 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 WORKERSCOMPENSATON LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATIO f81BN64ESFCTION 3700 OF THE LABOR CODE, 1 SHALL FORTHWITH COMPLY W OSE PROVISIONS. 1 DATE: APPLICANT. I WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LP TO ONE HUNDRED THOUSAND DOLLARS (i100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY i 1HEREBYRUNDER PENALTY IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE MSPERMIT OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV, C.). 1 LENDER'S NAME _ LENDrR'SAODRESS 1 I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION,AND HERESY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE J ABOVE-MENTIONED PIFOR INSPECTION PURPOSES. /1 -0 --EE NAME(PRINT) SIGNATURE OF PERMITTEE DATE �� aloe PRESS FIRMLY APPLICATION('- (� PERMIT P/C DATE V 60 NUMBER # ISSUE TYPE OCC DATE �wla,CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISID E STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAIVALUATION SFR(ADD/REM Garage/Carport LU Patio/Dock PooVSpa Z Z Re -Roof 0 Commercial M Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U U w LU Z+i�.1G p prof AA,,y� m d J Q U Z Q U w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE `llf SMIP p fi'y17 _, �, . Y 2111 ENERGY PIC -- �v "..I� (-� ENERGY PERMIT BUILDING ANLL�- RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, 30LDtNH0D— II0 COPY, (iittN—AppucanrS Copy ...... ------- tf 0 F DIA M 0 'N D B A R INSPECTION RECORD 1 1 FLOOR JI -!ST ......... . . I IA EQ'Al ng -i c -I 4 'T "FLAGE F(RI)NDATPON -td B,7AM . . . ..... .......... .. ........ .. .. . . ...... . ....... ... FINAI'l- BONI,) r. }.t RADNG . . . .... . . ........ (3 PV�lr, i.N� . ... ........ 'J A --- - -------- p'o E.L. 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