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Home My WebLink About12-0032---1 DEP RTMENT OF COMMUNITY & DEVELOPA'IENT SERVICE RATEJiERS 21825 Copley Drive, Diamond Bar, CA 91765 (909) 839-7020 Fax(909)861-3117 Building Inspection Hotline (909) 8 UIRE�v BUILDING PERMIT APPLICATION FIRMLY JOBSITE �O � V, / 6-h Tl r Rae �rDC/ 1 APN LOT TRACT OWNER L 117V-1 ryA- 0 ADDRESS Wagy�j�v� L CITY —0—��rJ.,ZIP — TEL. APPLICANT TEL, CONTRACTO7 wada "t ADDRESS N CITY ZIP TE % ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LJ - CENSE -CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.S BUSIN ESS AND PROFESSIONS CODE ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONST RUCT ALTER. IMPROVE. DEMOLISH, OR REPAIR ANY STRUC- TURF. PRIOR TO ITS ISSUANCE. ALSO REWIRES 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 LAY! (CHAPTER H (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO_ FESSK)NS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED FXEMP- TION. ANY VIOLATION OF SECTION 7031,5 8Y ANY APPLICAN T FORA PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): O 1, AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE YORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70,14, BUS - 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). ❑ 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW DOES NOT APPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CO.NTRAG TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. 8. E PC FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER a (COMMENCING WITH SECTION! 70OO) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLAS Y 0 LIC. NO. / / O Q I // DATE �� CONTRACTOR c►i/ r f oo e WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL I.W NTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 77W 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 BY SECTION 3700 OF THE LABOR CODEC. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED. MY WORXERS' COIMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER ( HIS SEC"PON NEEDNDT BE COhL3ETm OF TF= PER).4T IS FDR CNE HUNDRW OOL ARS (SITD) OR LESS) I CERTIFY T`•AT INN THE PERFORMANCE OF THE VAORK FOR WHICH THIS PERM17 IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER BOAS TO BECOME SUBJECT 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 LABOR COO . i S FORTHWITH COMPLY WITH THOS PROMS DATE: O APPLICANT: .� WARNING: FAILURE TO SECURE VNORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL BE SUBJECTAIN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 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 AFFIRIA UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR THIGH THIS PERMIT IS ISSUED ISEC. 3D27. CIV. C.). LENDER'S NAME LENDERS ADDRESS i 1 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 CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ASOV&MENTIONED PROPERTY FOR INSPECTION PURPOSES. � PERMITTEE SIGNATURE OF PERMITTEE DATE WHITE—Department Copy, YELLOW --Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREFr —Applicant's Copy DATECATIO NUMBEF12 DD,302�1C ISSUE IfTYPE DATE '0/// Q CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR O SIDE/SIDE STREET RW 0 - SIDE O PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM C0 Garage/Carport W Patio/Deck LL PooUSpa Z Re -Roof Commercial 5 M Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U [C H U w J w (7 Z Fn a w Q U Z � " rLe ✓bv w CONSTRUCTION PLAN REVIEW - ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: 4400 PRE -ALT FEE: TOTAL FEES COMMENTS RECPT. NO. qVAQ PAID BY IY4- VALIDATION WHITE—Department Copy, YELLOW --Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREFr —Applicant's Copy