HomeMy WebLinkAbout15153CITY OF DIAMOND BAR 8
- J — DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
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APN LOT TRACT
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CITY �L' R *•'ZIP TEL. 6/ i_ 01Cs4
APPLICANT TEL.
CONTRACTOR
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CITY /.x'1141- ry ZIP'1Z'3_7 TELfiC0,05i:i-713
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DESIGNER _
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FORTHE FOLLOWING REASON (SEC.7WI 5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESAPERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANYSTRUC-
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. ANYVIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).)!
01, AS OWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (S EC. 7044, BUST.
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 HEROWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFEREDFOR SALE IF, HOWEVEFA 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).
U I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC .W
70,14, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U -
CENSE LAW DOES NOTAPPLY TO AN
ONEq GFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW).
❑ 1 AM EXEMPT UNDER SEC. _— B. A P.C. FOR THIS REASON
DATE OWNER ._
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 70W)OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE 15 IN FULL FORCE AND EFFECT.
LICENSE CLASS _- d' _LIC. NO. L''
DATE 41•"- i,.r rJ7/ _CONTRACTORS ;.r%" "-Y -
WORKERS'COMPENSATIONDECIA TION //
I HEREBY AFFIRM UNDER PENALTY OF PETUIURY ONE OF THE FOLLOWING DECLARATIONS:q'
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
�— CO1111
AS PPOVIDFD BY SECTION 37DO 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 REWIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE,:
CARRIER____ .—._..
POLICY NUMBER
(ITSSSECTFON NEED NOT BEOOLAPtZrEDOFTHE PERMIT a FOR ONE HUNDREDCOU.WTS ($100) 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
WORKERS' COMPENSATION LAWS Or CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUEUECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE , I SHALL FORTHWITH COMPLY WITH MSE VIS NS.�—
DATE
•=T _�_�- APPLICANT:
.-
WARNING: FAILURE TO SECURE WORKERS' COMPENS ION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS IS 100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE: IS ACONSTRUCTION 1 ENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDERS NAME____
LENUE:R'S ADDRESS
I CERTIFY THAT I HAVE READ [I IIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I 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-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PFR EE E INT) 1
SICNATU,PE OF PERMITTEE DATE—
APPLICATION PERMIT �;7' J _3 P/C
DATE NUMBER #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW n
REAR ❑
SIDEISIDE STREET RW Cl _
SIDE
PROPOSED USE _
NO. DWEL. NO. NO,
UNITS _ STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAlVALUATION
SFR/ADD/REM
W
Garage/Carport
WPatio/Deck
U-
PooBSpa
Z
Re -Roof
Commercial
5
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
I 'LSC, A
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U
U
W
UU
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J
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F A r'
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CONSTRUCTION
PLAN REVIEW
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ELECTRIC --------------- —--._... -------�
PLUMBING _......
MECHANICAL
INSPECTION FEE _,_--___.___
ISSUANCE --''-- "—'--=---------
SMTP ---8=-'a --
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
RECPT NO PAID BY VALIDATION _-
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD -+Ile Copy, (3111:1=14—Applicant's Copy