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Home My WebLink About17264 (10) �x�t�� CITY OF DIAMOND BAR � DEPARTt1�NT OF COI��N:t.JNI'I'Y&I7EVELOPMENT SERVICEB 21$25 E.Copiey Ihive (909)860-3195 Fazt(909)861-3117 PRESS \h� BUILDING PERMIT APPLICATIdN FIRMt,Y � JOBSITE �� (;i � �r APPLICATIlJ�( PE9�MIT n P!C '� � A4DFiESS��`�"y� t� Jvt---��,��,__T_..._ DATE . ? "t�S-(�I Nt1MBER �� #'�� 1� � APN �t3T TRACT �_—_ D TEE �� y'_ fT}__ONST. GftOUP p C?WNER rt �.1-- � ADDRE � � tF ' � �.,,.f ZONING SETBACKS � CITY�� ZIP TEL. � FftON7 RW ❑ APPGICANT�" 7E1. �.r"��'/'Z REAR � z SIDEISIDE STREET_� RW ❑ ¢ GQNTRACTOR G�'�ti' - , �-�G=��(�_�— SIpE � ADDRESS %Y/j.f �"s .v •�-4�,�^_ --7 7 L � CtTY G- .,.�. ZIP %:1�F>TEL.��1;�� PROPClSED U5E �- l C'M�-+ �' �Z w ARCN/E_-� � 1 . � y . z DESIGNER G !;,^�.-� ��y��ec�,�-,,�u� � ADDRESS � --"�� Nd.DWEL. NQ. NO. cn UNITS STC}RtES � BEDROOMS � CITY ZIP TEL. � DESCRIPTiON S4.F7. FACTOR PSF ADJ.AREANALUATION � pWNER-BUILDER DECLARATlON p SFRIADDIREM p I NEREBV AFFIRM UNC�ER PENAI.TY OF PERJURV THAT i AM EXEMPT FHOM THE CONTRACTORS LI� GdfdBB/C.HfpOfl tt! CENSEtAWFORTHEFIX10WiNGREASbtf(SEC.709i.58U51NESSAN6PR6FESSiQNSC6DE:ANYCiTYQR (j� � CAUNTVWHICHREOUIREShPERMITTOCONSTRUCT,ALTER,IAiPROVE,OEMOLISH.DRREPAIRANYSTfiUG W peUOfDBCk W 7VRE,PRIOR TO IT5 ISSUANCE,AL50 RE�UIRES TI-IE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � .�,�- STATEMENi THAT HE OR uHE IS UC£WSEQ PURSUANT F(}TkE PROVtSIONS(SF THE C�NTRACT4A5 46 " """ .�r-, CENSE LAW(CHAPTER B(COMMENCIN6 WRH SECTION]W0)OF pIVI510N 3 OF THE BUSINESS ANP PRO� V' POOUSpB � iE551l7NSCO�E)ORTHATMEORSMEISEXEMPTTHEREFRqMANDTH[6ASluFOR7HEALLEGEDE%EMp� � U TION.ANYVIOLATSONOFSEGTIONI03T.5BYRNYAPPLIGANTFORAPERMI7SUB,lECTuTHEAPPLiGANTTO Z Re-Roof A CIVIL PENALTY OF NOT MOFE 7HAN FIVE HUNOREO�oILARs(S5oo).)�. � !..IIASQWNEROFTHEPROPEftTY,QRMYEMPi.OYEESWi7HWAGE5A5SMEiftSOi.ECOMF£NSA710A, � �Oti1tf18tG(87 � VnLL p0 iHF WOqK,AN�THE STRUCTUFE IS NOT INTENpED OR OFFE€teD FpR SAtE iSECJ04a,BUS�� J . � NE55 AND PROFESSIONS CODE�TNE CANTqACTORS LICENSE LAW OOES NOT APP�.V TO AN OWNER OF � PR6PERTY Nhi4 BUIEDS OR IMPR6V£S THERE�F1,AND WHO LKaES SUCH W6ftK HiMSELF 4R HEFSEIF ON (r THROUGHFIISORNEROWMEMpLOVEES,PROVIDEpTHATSUCNIMPRQVFM�ENTSARFNOTINTENDEDOR m � OFFEREOFORSALE.IF,HOWEVER,TH�9UILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCC]MPLF.- � fldN,THE OWNER�pUItpEfl Wil�HAVE THE 6UAD[N O�PROV{NG T4AT HE OR ShiE DID N6T BUtLD OR � IM7RQVEFORTHEPURP475EOF5ALE). W f�i,ASOWNEC{4fTHEPROPERTY,AMEXGLUSiVELYCANTftAGTINCaWIFMUCENSEDCt7NTMCTQRa" L'[ TO CANSTRUCT TNE PRW�CT(SEC.�040,BUSINE55 AYp PROFCS5iON5 CODE:TNE CONTflACTORS L�� VeIU2�iOf1 1""' ADJ.AREA ll1 CENSELAWDOESNOTAPPLYTbANONMEROFAFROPEH7VWHOBUILD50RIMPRWESI'MEREON,ANb � WHOC.ONTRAC75FORSUCNPRbJEC75W4THAGQ#�lTftACTOR{5}UGENSEDPL7RSUANTTO7MECOMFiAG C}URNTITY DESCRIPT{QN � FEE � TORSUCENSELAW,). � G i AM EXEMPS UNpGR SEC. 8.R C C.�OR TNSS REASON Q � �'�(�'�__,..... �=� .� � (,) V _ — __-- – , ' "Zc��k- � DATE OVINEF � � �t�` � _ '- U � IiCENSEQ CONTRACTORS DEC;ARATION W C.'L t HEREBY AFFIRM UNDER PENALTY 6F PEflJUiiY TNAT 1 AAA IiCENSED VN4Efl PROVISIONS UFCHAPLEft � p_ 9(COMMENCINGWITHSECTION7o0o)OF�IVISION9OFTHE9USINESSANDPROFESSIONSCODE,ANO z W MY LICENSE IS IN fULL FONCE AND EFLFCT. +� m � LICEN5E/C'�LASS�_�y�_ __ LIC.NO. ✓�/ � �_I � �� DA7E��_,�,�_� �+5.EL�_ CqNTRACTOR�i7��Z,- �1 W � WORKERS'COMPEN5ATION DECLARATIQN Q � I HEREBYAFFIRM UN6ER i'ENALTY Of PEftJURV ONE OFTHE FOI.tOWiNG�ECLARATI�t3S� Z � _.._..__IriAVERNOWiLIMNNTAiNACERTiFICATE6fC�NSENTTOSEl.F-iNSUREFORWOftKEftS' a 2 ,�,L CAMPENSATION,AS PROVIDEp BY SECTION 97oa QFTHE LABOfl CDDE,FOR THE PENFORMANGE U OF TNE WL7RN FOR WHICH THIS 7ERMIT IS ISSL1EfJ, w � � � W I HAVE ANU WILL AIAIN7AIN WORKERS'GOMPENSATION INSURANCE,AS REqUIREDBV S�CTION Q374Q OF THE tABLIR COOE,F4ft THE PERFORMANCE OF THE WORK F(7R WNIGH TNIS PEflMiT IS - �•��.�� " ^{ ISSUED.MY WORN;ERS�'COLMPENSJATW N INSURANCE CA�R AND POI.IG NUMBER kRE: CONSTRUCTION ��Jr/., +- �t/ j cnRfuEa...��(�! G-'T� G j„"'G.�sy� �.. ' ��[' . . PLAN REViEW ,� + zPOLIGV NUMBER, -- _.. ELECTRIC 1 . �i „� ._.... .. .. .. � (IHISSECI�N]NNE�>N07BE�Mf'IEfEDOF1TIEPERMf"ISfpRONEHUNCIFlEDDOLLARS(E100)017LES5). PLUM6ING _ tl! — Z I CERTIFVTHAT IN THE PERFpqMANCc OF THE WORK FOR WHICHTHIS PERMIT IS ISSUEO,i MECHANICAL C,S' SHALL NOT EMVLOY ANY�ERSON IN ANY MANNER 50 AS TO @ECOME SUBJECT TO THE � �� — {rj Wpq%ERS'L13AiRcNSAT10N LAWg pF CAtiFORNIA.ANOAGftEE THAT 7F I StiOVLD BECOME 1NSPECTION FEE = SUOJGCTTOTHEWORNERS'COMPENSATIqNPRpVISION50F5ECTIOIV37000FTNELABOR /�. GOpE,1 SMALL FCRTNWITH CpMPLv WITh'TNOSE PPOVISIONS. ISSUANGE ��C'�/ Q p DATE: ,_ AVPLICANT: J,�,_ _ SMIP ��L� � . "'� WARNING:FAILURE T05E��.CURE WORKERS'COMPENSATIOM1 COVERAGE IS UNLAWFUL,ANp SHALLBE ENERGY PJC � ,. _ _. _ � SUBJECTANEMPI.OYERTOCRIMINALPENALTIESANOCNILFINESl1PTOONEHUNDRE07HOl15AND ENERGYPERMIT OOL(,ARS(Si�.WO).tN A6DIT{pN TQ THE C6S`.OF C6MPENSA7K5N,QAMAGES AS PROVI�ED FflR IN . ,,,_ J SECTION31q80FTHELA130PCODE,INTEPEST,ANpATTpRNEY5FEE6. ��C C[ RE7ENTION FEE: 1 QGON57RUCTION LENDING AGENGY PRE-ALT FEE: „ � iHEREBYpFFipMIiN(IFpPENA�TYO�PERJURYTFATTHEREISA�NST.RUCTIONtEh'OINGAGENCY ^ � FORTHE PERFOflMANCE OFTHE WOHN FOFI WHICH THIS PERMIT IS ISSIJED(SEC.309�,CIV C.). "' -'"' -- W T_ � LENOER'S NAME�,.� �� "" F— LENDEFSAUORESS —4 ��J �'T_�r � � � — — TOTAL FEES � Z•`l�( �-�`-� .�Q � I CEflTtFY THAT i HAVE ReAO THtS APp�ICATi4N AN[5 STATE THAT THEA84YE INFORMATKK�!ISGOflftECT. � IAOREETp COMPLV WITH ALLCITY AND COUNTV OqDINANCES AND STATE L4WS REIATING TO @UILDING � CONSTRUCTION.AND HERE6YAUTHORI2E REPFESENTATIVES OF THIS CDUNTY TO FNTER UPON THE ^�� r� �' —,,,,,� z ABOVE-MEN NED PflOPEiiTY FOR INSP CTVON PURPCSES. } o � GOMMENTS o�� - � �f n t ,�� `. �' ,�1 r�►�t _�.__. m PERMIi7EE E(P T� Y .� �� . � �1 � Q . S _ U) . y�.� . ,. — — _._ .�.._ � StGP2A7URF PERAAIREE OATE � RECPT.NO. PAIp BY VALIDATION � WHITE--Department Gopy.YEILOW—Finance Gopy,PINK—Assessor Copy,GOLDENF7Q0—File Copy,GREEN—AppiicanYs Copy 32�1.��t � �`Y 4�:i€ i' kh ��*S`��'�'� '�''`�� 5� �'� f� �� r,nr'€� 'ti�� ' ' r��' �.�� .. , . �'. � , , a ,'�'��`�r;� �a a�� ?3-�� :�.;� �� . �. �� ' � ��,fa�.. �2��t�' _ 63�c�-�- . .....� _ �a,�....,... �,1.�. ,�� : _ _ _ _ � �a. , , �� <� � � �� _�� _ �.�r�� b � ��_ _ _ � , � , - r,,., ; � � . i�. 4 �. .. . . .. .. . .. . . . .. t �y¢ i.„ �: ...... . .. >/,', > . w �. ' �� 1 ... .. CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE ADDRESS-144'�1,(. APN LOT TRACT OWNER s't-i-- ADDRE&L/ 1--9' CITY ZIP TEL. APPLICANTd r.jTEL. CONTRACTOR Go e-c 1 ADDRESS%d 1-�sv.'- ZIP TEL. CITY IJG ARCH/E ! 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 FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY 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($500).)'. ^I,AS 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 OP 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). ^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 TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^I AM EXEMPT UNDER SEC. B. &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 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT. .�,7�{� ^'J NO //f2/ LICENSE CLASS .� LIC DATE 4 t� CONTRACTOR- 12� 2/ WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: -1 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. /^' 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 WORKERRS'COMPENSATION INSURANCE CARRIER AND POLIC NUMBER ARE: N / �c- CARRIER C z• POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($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 OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE,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($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 AFFIRM UNDER PENALTY OF PERJURY 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 CERTIFY THAT I HAVE READ THIS 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-MEN NED PROPERTY FOR INSP CTION PURPOSES. PERMITTEE E(P T SIGNATURE PERMITTEE DATE W C7 cn 1- P/C I APPLICATION PERMIT NUMBER 7^ DATE b4 ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE � 7 PROPOSED USE E L t-+ ('/Z LEA rr N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck tL Pool/Spa 0 Z Re-Root Commercial M Valuation ADJ.AREA QUANTITY DESCRIPTION FEE CC E Liv L Z L�{- U W J W 0 Z a UU Z S U LU CONSTRUCTION -(F/ G G I PLAN REVIEW ELECTRIC� •L; PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP L) ENERGY P/C ENERGY PERMIT RETENTION FEE: C L PRE-ALT FEE: TOTAL FEES c i�2-7•OO D J fl GL COMMENTS T) ..- RECPT. N0. PAID BY fl-VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy