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Home My WebLink About16517 (9) � I / CITY OF DIAMOND BAR f( - DEPARTMENT OF COMMUNITY&DEVELOPMEN'T SERVICES j� � 2 tb60 E.Cop2ey Urive Suite 19� (944)Sb0-3195 Fa�c(9Q4)8b1-3117 PRESS ��TM'�� BUILDING PERMIT APPLICATION FIRMLY o DDRESS�,�__�� ,�J"t��f, APPLICATION L_}�-��r NUMB R �� #/C _ DATE `�.} � c� — ISSUE 'fYPE QCC APN LOTv TFiACT 3��'r.�(•� DATE CONST. GROUP p OWNER �G,+� �'--�;,��E S ADpRESS_.,,�;��y(,�/ �['4„��jX"�.�; �i f�'s -�7/f./I ZONING SETBACKS � CITY.��IJ, fi i'_ ZIP '��;2L3/e� 7EL. `�• � REOR � RW i l APPUCANT ^ TEL. SIDE/SIDE STREET RW d � G4MTRACT4R_�� SIDE � ADDREBS �-. �� CtTY ZIP TEL. PROPOBED USE � �(.* � ARGH/ENG/ � DES�GNER ' �'T�.'�_�"aS� �;:��C-.� NO.DWEL. NO. NO. CITY S y� IP � TEL. "� UNiTS STORIES BEpROOMS_._ ADpRES_ _ _ � -�``�f-r�.��c�t�:.:,= 7..�'..� .�2-`,�.�.�, �y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA7IQN gFR/AD0IREM O � I HEREBY AFFIRM UNDER PENAI.TY OF PERNRY THAT I AM EXEMPT FROM THE CONTMCTOpS U� �d�8�81Ca�Dn t,LI CEHBEUWFaiTHEFOIIONRiRAEA50N(SEC.70.91.58US�7ESSANDPF�FESSMONS(b6E:ANYG7Y6p (n S.2 COUN7yyyMq�qE(]IJIRESAPERMITTqCO1J5TRUCT,ALTER.IMPROVE,bEMOLISH,ORFEPAIRANVSTAUC- W P9H0/DBCk �� NRE,PHIQR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOfl SUCH PEFMIT 70 f11E A SI�NED � ST�ITEMENT THAT NE Ofl SHE IS LICENSED PURSUAN7 TO THE PROV�SIONS OF hiE CONTiiACTORS l4 CENSE UW(CHl1P7ER G(CAMMENCINO WIIN SECTION 7000)OF DIVISIGN 3 4F THE BUSINE55 AND PRO- � POOI/Spa fES3KlNS GODE}4R iNAT}IE OR SHE IS EXEMPT TNEREfft�hi AND tHE BA313 fOR TNE AI.�E�ED EXEMR- 710N.NtYVIfSLATKk10FSECT74N�o31.58YANYAPPLiCANTFORAPERMITSUBJECTSTMEAPPUGPNTTC7 Z Re-Roof � A CINL PENAA.TV OF NOT MORE THAN FNE HUNORED DOl.1.AR5�55oa).): � �i.T5M1MEflOFTHEFRQPERTY,OFMYEMP�OYEESWtTFfWA9ESASiHEiR$qLECqMPENSAT'KKJ, G� COrti/f�etCiel WILL p0 TNE 1VORK,MID'�iE STRUCiUFE IS NOT INTENpED OR OFFERED FOR SALE(SFf.,.7du,BUSI. J NESS AND PROFESSIONS CODE:THE CONTRACTppS�ICENSE I.AW DOES N(7T APP�Y TO AN OWNER OF � PF�+ERIYMh108VkDSOR7MP1�YE57HEREON.At�WrtODOESSUCHwoRKFN1.iSE�FOFlNER5ElFOq � CL T71ROU(3HMISORHERONMEMPLOYEES.PROVIDEDTHATSUCHIMPR9VENENTSApENOTMTENdEDOR m � qFFEREQF4RSAlEIF,FfC)WEVE0.�17E8UILpINGOq1�/PROVEMENT1S50tDWlTHIMONEYFA.90FO�MPIE- � T10N.THE ONMER�BUKDER WILL HIME THE BUHpEN OF PqOViNG TNAT NE OR SNE DID NOT BNLD QR IMPRLIVE FOR THE PURPOSE OF SALE). �t,AS OYMIH�i OF THE PflQPER7Y,AM EXCIU$IYEIY CQN7PAG7MK XMTH CtCENSED CXXiTRACTOAS � 70IXINSTRUCT THE PROJECT(SEC.704�,9USiNESS ANp PROFESSIIXJS CODE:THE CONTAACTORS 41- VBIUdIiDfl ADJ.AREA___ '� W CENSEUWpOE5NO7pPPLYTOANOWNEROFApROPERTYWHOBUtLOSORIMPROVESTMEREON.ANb -- � WtK)CONTMCTSFORSUC#iP�JECi'SWiTNACOMTNAC'TOR{S}l.tCENSEDPURSUANTTQIHEC�14TiUG QUANTITY DESCR�Pt"ION FEE � TORSUCENSEUW.). O!AM F7tEkiPT UNpER SEC. 6.a fl.C.FOR THiS REASQN Q U � ......--- tC DATE OYYNER�___. _ � ,''� W Fs[ LICENSEp CONTfiAGTORS 6EGLARATION W � iL i#1EREBYAFF�flMVNDERPENRlTY4FFER7URYTFbtTtAMt4CENSEDUMDfRPAOViS#}N59FCHAPTER � , p_ q(COMMENCINC3 WITH SECTKKJ 7000)qF DIVISION 9 OF tHE BUSMESS AND PROFES61oNS CODE,ANO Z 4 I �' L. �K) MY LICENSE IS IN FULL FbPJ�CE AND EFFECT. m � UCENSE CLASS�I--�LF— LIC.NO. �./ ��_�,„�� j .... � pATE� �Y Y�� CONTRACTOR ...�`I_j.�.'-�'.�FFBGrz- a' .—. 13J � WORKERS'COMPENSATION DECLARATION � Q � IHEREB1}AFFIRMiUNDERPi:NA1.TVDFGER.7URVONEOFTHEW�t6WiNGDECLAflATIONS�. U _'— � j/ Z C� �I? / Ii,1YEMlDriiLCMAiNTAiNACERTtFi(:AiEOFCONSENTTUSElF-INSUAEFORN°ORKEftB' S ..�—.... COMPFNSA710N,q5 PPUVIDE[?8Y SECTION 37aa qf THE UBOR CODE,FOR THE PERFORMANCF, U ,,,_ a . F TNE WQPK FOR WHICM THI^a PERMIT lS ISSUEO. W � � � 1 HAVE AND WILL MAINihIN WQRKERS'COMPENSATION INSURANCE,AS REUUIRE�BY SECTION ((('''``````�� d� 3TW OFTHE LA80R Cq7E,FORTHE PERiOR1dRNCf oF TNE WOWS FOA WHICH THIS PERMIT IS �,!'";'_ ,,f�'� — — ISSUED. WORKEHS'GOMPENSQION INSURANCE CARRIERAND PQLICV NUMBERARF.� CONSTRUCTION �,;.{/_Z,r � _ � ^ ' � � a Pi..AN REVIEW � POLICVNUMBEH� p � CARRfEA' z �L�L� -j y�L/ J �¢�--- ELECTRIG d �—...... ..�. ` "�y 0 (M1ASSECi1CMNE971qT6EWIM�LEfEDOFhEPEP1M45FdR�NEHIN�[NIEDIXA.LM4(51�D)OHLE55). PLUM8ING _ , �! .� �,} W I CERTIFYTNAT IN TiE P[(iFORMANCE OF 7HE W9RK FOP WHIGHTMIS PERMIT IS ISSUEtl,I MECHANICAL � _ , (,'� SHAl1 NOT EMPI.pY ANY PERStlN 1N ANY MANNEP 50 AS 70 BECOME SUBJECT'q THE � WOftKERS'COM(PENSATIQNCAWSOFCALiFOftN1A.ANDAGREETHA7iiiSH(Jiri08ECotdE (NSPECTIONFEE ,_,., � SUB.IECTTpTHEWORKERS'CiJMPENSATIONPROVISION50FSECTIONa]MOFTNEIABDR ��\ 't"'�`�� CADE.ISHALLF�RTMNITHCCMAPLVWITNTNOSEPROVISI�N�Sr� FSSUANGE ___,,,,,,_ _,_ c3- \ (:� ' i {� p OATE: '��_ APPLICANT: ��L- SMIP _..._ � ENERGY P/C J W�flNINO:FAILUR&TO SECUflE WOflKERS'COMPfNSATICNJ COVERAGE IS UNLAWFUL.ANp SHALI.BE -- -- � SUBJECTPNEMPIOYER70��RIMINALPENALTIESAN�CIVII,FINESUPtOONENUNDftEDTNOUSAN4 EMERGYPERMIT .r DOE.URS t55qD.00D},IN A1��7TION LO THE C6STOf COMv�NSAT{^JN,DAMAGEu AS PRQViDE6 FOR M —�- � SECTIf7N J70B OF TNE LABpH CO�E,INTEREET,ANpATTORNEY'S FEES. RETENTION FEE: , _,___, � CONSTRUCTION LENDING AGENCY pR�-AL7 FEE . . O � I tiER£BY AFFKIM UNOER PENAlTY OF PE{1JURY THAT THEftE t$A G3NSTRUCT�ON IENDM9 AGENCY _ _ _ _ FOR TNE PERFOflMANCE 17F THE WOPK FOR WHICH THIS PERIAIIIS ISSUED(SEC.39d�,CIV,C.�. ` ! � � LENDER'SNAME_ _L�. —..._ ._.. ._ i_^ t.ENDER'SADORE53_ _,_„_ _ _ � i CERTIFY THAT I MAYE F{EAD TH5 APPUCATION AND SiAT£TttA7 THE ABOVE MFORMATqN iS GOtiR£CT. TUTM�FC E� �� '�" �' W I AGREE TO COMP4Y WITH ALL CITY AND CAl1NTY pRDINANCES AND STA'fE UWS RELATING TO BUILDINp � CANSTRUCTION.pNOHERE6YA:JSHOftIZEREPRFSENTATNESOFTHISCOUNTYTOENTEP,UPCJNTHE � ABOVE-M�Eti,,T"�iDNEDPi10pEATYFOpiNSVEC NPVRPO5E5. CCIMMENTS � "�./ �i�� "�4.�'� — • _.—. m RERMITTEE NA1AE{PP1NT)� / __....... � ��L� � Si�t7 EOFFEftM�'TEE DATE ( i � RECPT.NO._ • � PAID BY �V� VALIDATION — WNI TE—DeOertment Copy,YEIIQW—Finar�ce Copy,PIiVK—Assessw Copy,GOLDENR0t3—FiieCopy,GREEN—Appiicant's Copy ��`�"� �� .�� 3��'��'�t'�� W � � . � � - � � • � � � _ �� _ ___ . ___ _ .�� _ _�_ _ _.__ _ , _ . _ . _____ _ __ -_ _ . r� � � �; x�u �,. �� .�. . �� . _ _ ., ____ _ . _. __ _ _ ,.. _ _ � r,�"3C,'�w �r :� zz � . ��-1� '� _. w_ _ _ ._ �..— — ... . -- _ � i "� "'.'�� ii" i` � � � W .,, x �< . , , , , , �. , __ _ __ ____ � '._. : _ ,` _ _ _._ _ � � �.,^`� ," ' '� � _ __ __ . __ _�,. _.......� _ � ., _ � ._ � y � ..;. , :'.,�- �_ . , .l >_ . a � _ .. ....__. . .._,. ,. ....._ .._._... .,.__.. . . __., ._. ...._. _ ,-, ._.. . .__ .___._ �..____ _.. ',� <s�i-- ;�c ''` " ` _a __ _._ ___. _ __ , . _ . . _ __ _ _.. t �-,,�.k,s> ...__ ;,, +zi �`�' ;'�9� ��. . __ , .._..�. . .... ..._ ...._ _..__ . . .. .. .._. . , .__ ..... .__. .._... ..... �. _ �-.a ,{s�- .��-., , a� �'�t .. �. .. ... � ��.. t . _.__.._,.. .. . ....._. ___ _... . .. ... ..... _.._ .... ._.. ....... ... . _ . � �",j�,� � ... _�___ _ _ _ _ ___ _ __ ._ _ . _. � }�tg"; "� s '-:';t�i�, - __. ___�,,_—,.. __..____ __., _,_._ �.„._ _ _�_ �, , __ , — - _ �T�.�, t 4 t .�S�`,,. . .. ".4 ��. ,-; , r E ,F�% _ . --'. . __ _- _' .. . , (. C, '.F _ __ �,_ . __ _ . . .__ .. _ ,. , � �_�� _ .__, _ _ __ _ _._ . ..,�_._ _ __ ____ _.._ _ _ __ ��i�nk. i „''d(s _ .__ a _ ____.� _ __. ._.._._-. -� _ _. ____ _.__ .._..___.. _ e � � � _. ._ ,i��: . I . . . _ � . � . .' �. . ,• " , ., _ ,. . �r . �. .. � _ _ ._. __.. � _ ._ .. . � _ . ._ __ __ . . �. � � _ ��1 �` � � � _ � �—� .� � �� _ � __ ._ . _ — -- __ _ _ W_ _ _ _ _ __ — — { _ � � � �, �� ,r� ._ _ _ . __ — � s� �;. � __. _ _. ___ . � ��. :��^�� '��, "�� ; _ _ __ . __. __. _ __ _ ._ . _ . _. __ ___ ___ . _ _ _.� ____._ _ . __ __ . _ _ _._ _ _ __ _ _ _ _ _ _ __ ._.. _. _ _ . _ ._ _ __ __ _ _ __ _ _ _ _ _ _ __ _ __ _ _. ._ __ _ ,a�`� �,��'��`��`��a�'"�� .-� _._ _ _ �' � � ,� _ _ __ _ � � _ ..� _ . .. _ _ _ . . _ _ � ,,� � � �, , � � ; ,� p�i � �� „ � ,�u � _. __ _. _ _. _ _ + �.� t� _� � n� � n _ _ _ r r� _ __ _ _ _ , w �, � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21660 E.Copiey Drive Suite 190 (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRM�Y JOBSITE ADDRESS J 70 APN�OT TRACTS OWNER p L+� r,L,4A4 ADDRESS CITY.t u•)e-ZIP!TE�. r'- APPLICANT TE�. CONTRACTOR C' ADDRESS CITY ZIP TE�. ARCH/ENG/ DESIGNER y r ADDRESS CITY IP.f 22•""TEL.7��j%a�Q-'1 7 7 OWNER-BUI�DER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESA PERMII�'0 CONSTRUCT.ALTER,IMPROVE. DEMOLISH.OR REPAIR ANY STRUC- TURE. PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE t.AW(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 A�LEGED EXEMP. TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500).): ^ 1.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION, WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044,BUSI. NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�AW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUI�DS 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 FORSA�E IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION.THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR IMPROVE FOR THE PURPOSE OF SALE). ^I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRP,CTORS LI- CENSE i_AW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE�AW.). ^ 1 AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DEC�ARATION I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY�ICENSE IS IN FUL�FORCE AND EFFECT. LyiG LICENSE CLASS-T�IC. NO.J . DATEf�fr[!',�,f CONTRACTOR WORKERS'COMPENSATION DECLARATION IH AFFIRM UNDER PENA�TY OF PER7URY ONE OF THE FOL�OWING DEC�ARATIONS: i HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t_ABOR CODE, FOR THE PERFORMANCE IfOF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 HAVE AND WI��MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: r CARRIER oL 7 POLICY NUMBER-�AV��,Ir�'J_"!,IS. (THIS SECTION NEED NOT BE COMPLETEDOF THE PERMIT IS FOR ONE HUNDRED DO�LARS($100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB]ECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS 2u�Lif DATE: APPL.ICANT WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UNt_AWFUL.AND SHAL�BE SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND DOLI�,RS($100000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. INTEREST,AND ATfORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ED PRO ABOVE-MENTK)N PERRTY FOR INSPEC bN PURPOSES. NE DP OP PERMIITEE NAME(PRINT) 4 EOIfIEE D ATE APP�ICATION 11 V PERMIT P/C Y 1 DATE 1 NUMBER# ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE PROPOSED USE N0. DWE�. N0. NO. UNITS STORIES BEDROOMS DESCRIPTION S0. Ff. FACTOR PSF AD7.AREAIVALUATION SFR/ADD/REM w Garage/Carport W Patio/Deck LL PooVSpa Z Re-Roof Commercial Valuation AD7.AREA QUANTITY DESCRIPTION FEE J U cc U W UJ Z U W CONSTRUCTION PLAN REVIEW E�ECTRIC P�UMBING MECHANICAL INSPECTION FEE \\ ISSUANCE SMIP ENER6Y P/C_ ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTA�FEES Q,� L COMMENTS RECPT. NO. PAID BY g's VA�IDATION WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy