HomeMy WebLinkAbout15157 (20)10,110XII HAft d
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY k DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
TE
ADDRESS
APN LOT TRACT
OWNER _44/X6A)
ADDRESS 4=41-1 -
CITY ZIP TEL. 57
APPLICANT TEL.
CONTRACTOR
ADDRESS °•
CITY 40a _ .44me ZI TEL 16�
ARCFYENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSNESSAND PROFESSIONS OODE: ANYCITYOR
OOUHIYMHOCH REOUIRESAPERMRTO CONSTRUCT, ALTER IMPROVE, DEMOUSH,OR REPAIRANY STRUC.
TURF, 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
FCENSE UAW (CHAPTER 6 (COMMENCING WITH SECTION 70D0) 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 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF MOT MORE THAN FIVE HUNDRED DOLLARS 1650D).):
0L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
N,
VHLL DO THE WOAND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SED 7044, BUSH
NESS AND PROFESSIONS OODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHOBULDS OR IMPROVES THERECRAND 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 F HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE
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
O L AS OWNEROF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. TDMA, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TOTHE OONTRAC-
TORR LICENSE LAW.).
O 1 AM EXEMPT UNDER SEC. B. S P.C. FOR THIS REASON
GATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
S (COMMENCING WITH SECTION WIN) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSEUC. NO.
CL S �_
DATE 4!:�' CONTRACTO 41:�53
WORKERS' COMPENSATION DECLARATION `
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAT {r
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WOR
COMPENSATION, AS PROVIDED BY SECTION 370D OF THE LABOR CODE, FOR THE PERFORMANCE
Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,
I HAVE`AND WILL MAINTAIN WORKERS' COMPENSATKNN INSURANCE, AS REQUIRED SY SECTION
97000E THE LABOR OWE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER f
POLICYRUMBER -�
pT6B SECTION NE®NOTBEOOAIPLFTEDOFTFE PEAMi6FOR ONE IfAOIiED DOLLARS is LESS)
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU D, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' CCMPENSATIN LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD SEGO
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
SHALL FORTHWITH COMPLv WITH THOSE P
DATE:'APPLICAHT: C
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION AOE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (6100,000), N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS AOONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. G).
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATIONIS CORRECT.
1 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 -MENTION FOR INSPECTION PURPOSES.
[ER1Mrl`TE
i
SI&IqArUP9 OF DATE
PRESS
FIRMLY
APPLICATION &0 PERMIT .�%{ PIC
DATE ll!!�� NUMBER `J It
ISSUE TYPE OCC
DATE CONST, GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
Exyp D US
NG
a79 r - '
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADO/REM
Garage/Carport
W
PaUc/Dock
LL
Pool/Spa
ZRe
-Roof
CI
Commercial
5
m
Valuation ADJ.AREA
OUANTITY DESCRIPTION FEE
U
S
F-
U
LU
LU
0
2
Alv
tz
9
S NEE
ZISSUANCE
SMIP 11 ] AI fiIQ� 1
ENERGY P/C
ENERGY PERMIT ( ITV Cti' D- A.L" UL
RETENTION FEE: lit, III I NG AN v Ly
PRE -ALT FEE:
TOTAL FEES - Q
COMMENTS
RECPT. NO. PAID BY VALIDATION
WHITE—OapaAment COW. YELLOW—Finny Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
CITY OF DIAMOND RR
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