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Home My WebLink About15006 (15)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY &. DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITEO ADDRES APN LOT TRACT OWNER � C• ADDRESS D U(C ir. 4210 a CITY 7.IAI�M1CIJi�y�LZIP G%fiL•cTTEL. APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP TEL. ARCFVENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOKLOWNG REASON(SEC 70.91.6 BUSINEWAND PROFESSIONS CODE:ANY CITYOR COUNTY WHICH REOUI IESA PERMRTO CONSTRUCT,ALTER, IMPROVE, DEMOLISH. OR REPAIRANY STRUC- TURE. PRIOR TO RS 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 LL CENSE UW (CHAPTER 6 (COMMENCING WITH SECTION 70X) OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE IR EXEMPT THEREFROM AND THE Wig FOR THE ALLEGED EXEMP. TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6600).(: O LAS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WINO 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 MOIYETIER. THE BUILDING ORIMPROVEME NT IS SOLDYNTHINONE YEAR OFCOIPLE- TION. THE OWNERatALDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DD NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC 701, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW ODES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WAD CONTRACTS FOR SUCH PROJECTS WITH ACOMRACTOR(S) LICENSED PURSUANT TO THE CONTRAS TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC B. S P.C. FOR THIS REASON DATE h — OWNER 1 LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER S (COMMENC:Q WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE, AND W LICENSE LOIN FIAT fORCEAND EFFECT. LICENSE CLASS UC. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATI N& I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FCR WORKERS' COMPENSATION. AS PROVIDED BY BECTON 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 REOUIRED BY SECTION 37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (TF6SECTgN NEEDNOT BECOAFLETEDCFTHE PEROT 6 FOR ONE MINDREDDOlARSRIO%ORLE55) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT B ISSUED, I SHALL NOT EMPLOYANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' OOMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR OWE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (6100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTER EST. AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM LNDER PENALTY OF PERJURY THAT THERE LS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 151SSUED (SEC. 3067, CIV C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 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. C s rU, EE NAME(P l aA S R DAT PRESS FIRMLY APPLICATIO /Aj PERMIT j �M P/C DATE Vv NUMBER -f - IT 8 ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE C iSJk \ 11 ^Tl le \GC_�i�[.l �-i4fLi"14� NO. DWEL, NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM 00 Garage/Carport LWLI PatloMeCk LL PooVSPS ZRe -Roof 45 Commercial In Valuatlan ADJ.AREA QUANTITY DESCRIPTION FEE J a U it U W W 0 Z_ J a Q U U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE PAID -L ISSUANCE SMIP �7T.T. onnn 570 oT� ENERGY PIC MAY F" ENERGY PERMIT irk # 3 D1 ARROND� .B AR TC)F RETENTION FEE: �V'LL7l'*1i�TJL-NnS' YL-� A i PRE -ALT FEE: TOTAL FEES Q !F-0– F— -,COMMENTS COMMENTS RECPT. NO. PAID BY 00 VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor COpy, GOLDENROD --His Copy, GREEN—Applicant's Copy