HomeMy WebLinkAbout10704CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS ll��
APN L RACT
OWNER
ADDRESS Z
CITY ZIP TI
APPLICANT L.
CONTRACTOR
ADDRESS_ +L C -
CITY Zlt7f2 2_.TEL.
DESIGNER
ADDRESS
CITY ZIP _ TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESA PERMITTO CONSTRUCT,ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC-
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. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6500).):
CII, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR 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 IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR
THROUGH HIS OR HEROWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVER. THE BUILDINGOR IMPROVEMENT IS SOLD WITHIN ONEYEAR OFOOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
LI I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI.
CENSE LAW DOES NOT APPLY TORN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
IJ 1 AM EXEMPT UNDER SEC. . B. A 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 O THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FOg�E MJ{2 EFFECT.
LICENSE CLASS _ y2f (,�i _ UC. NO.
DATECONTRACTOR
WORKERS' COMPENSATION DECLARA N
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 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 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 A—,"
POLICY NUMBERL/
GHISSECTIONNEEDNOTBECOMPLETEDOFT 41 EFORCNERMREDDOLIARS(SIOD)CALESS}
1CERT14ALL NFY OTHAT IN THEY PERS MANC MN E. IS FO A FI I THIS PERMIT IS' TH ED.1
SHALL NOT EMPLOV ANV PERSON ISI AN N ERS S6 OME SUBJECT TO TME
WORKERS' COMPENSATION LAWS O}4+�'iAL OR , A AG THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPE(QOATI NP OF SECTION 3700 OF THE LABOR
E I HnALL
WITH COMPLY TH TH IONS.
DATE: ;7 APPLICANT: _._._..._ _
WARNING: FAILURE TO SECURE WORKERSCOMP COVERAGEISUNLAWFUL,ANDSHALLBE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES IL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (6100.000), IN ADDITION TO THE COST OF Cb. ENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37030F THE LABOR CODE, INTEREST, AND ORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDER'S NAME
LENDER'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE COWY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSWTUO.T.ERER'Y AUTNORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
Y FOR INSPECT N P4RPOSES.
9L. _
PE E E (PRINT)
SIGNATURE OF PERMITTEE DATE
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
PRESS
FIRMLY
APPLICATIONCJ PERMIT /C
DATE // NUMBE #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW U V
REAR I-1
SIDE(SIDE STREET RW ❑
SIDE U
PROPOSED USE X'1 (I to 11-f
NO. DWEL. NO. -{ NO.
UNITS S STORIES ZZIBEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADDIREM
T4
Garage/Carport
WPatio/DGck
LL
Pool/Spa
IL
Z
Re -Roof
p
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
Q
U
F-
U
LU
J
W
0
Z
m
a
J
H
U_
Z
Q
2
W
CONSTRUCTION
111
35
ELECTRIC
` to
PLUMBING
MECHANICAL
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
141
TOTAL FEES
COMMENTS
RECPT. NO. PAID BY _ VALIDATION
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