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Home My WebLink About19091H 0 O W J lL J EZ W O W d Cc W H Cc W LL CD m a S CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21825 E. Copley Drive 4, (909) 860-3195 Fax (909) 861-3117 PRESS """ BUILDING PERMIT APPLICATION - FIRMLY JOBSITE �y ADDRESS APN LOT TRACT OWNER L!L / n/y I / T-r DV Ale- /-4Z. ADDRESS v/ -'--) n "d CITY 2>»Lr'O!�STEL. to 4l/6 APPLICANT ZCTEL 6! CONTRACTOR _ ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITYOR COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT, ALTER IMPROVE, DEMOUSH.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 (ODMMENCING WITH SECTION 7WO) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONSCODE) 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 (SSW).): ❑ I, AS OWNER OFTHE 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 OFI IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER-1 EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF HOWEVER THE BUILDING ORIMPROVEMENT 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). ❑ I, AS OWNER OF THE: PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70", BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON DATE OWNER - / ` L LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTKNI 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIG. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL A/ IMTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 37M 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 SECTON 3IrW OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICHTHIS PERMIT IS ISSUED. MY WORKL.RS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER _ MASSECTION NEED NOT BE COMPLETED OFTHE PERMIT B FCR 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' COMPENSATON 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 HUMORED THOUSAND DOLLARS (S1D0,000), IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370E OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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. 3W7, CIV. C.). LENDER'S NAME LENDER'S ADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, T :BY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONRTY FOR INSPECTION PURPOSES. SNKTFIIERMITTEE A E , APPLICATION .J�PERMIT Rog P/C DATE ss�� NUMBERI L g ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE c G- NO. DWEL. L O. UNITS STORIE BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAIVALUATION SFR/ADD/REM (0 Garage/Carport WPatio(Deck LL POOVSPa a Z Re -Roof Commercial m 1 - Valuation ADJI.AREA UANTI DESCRIPTION FEE J Q _U U W LU C3 Z r1 m J ` a t J Q U_ Z Q a_ U W cq L �� CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE L SHIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES C�L'--G'lF '�.(}"17t�D.'I�'(..✓4t... -\. � `" V b �� COMMENTS ✓k'1� i I An,u.,. t, c, z RECPT NO. Lj'PAID Y VALIDATIONV WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Co OLDENROD--File Copy, GA//EE,,EE,, N—Applicant's Copy DIAMOND IIJAR i 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 APN L.OT TRACT OWNER L!L-/ A/O / T-C /t-1)y/A/ G L-/L_ ADDRESS / [3— IL C>G"C t" y% —'— o fir/ CITY V p TEL. C'eA 1q4. 16 APPLICANT Z—a- 4 P t// NGc /I -A TEL 6i CONTRACTOR _ ADDRESS CITY ZIP TEL. ARCH/ENG/ 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 PERMITTO CONSTRUCT, ALTER. IMPROVE, DEMOUSH, OR REPAIR ANY STRUC- TORE, 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 B (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 FORA 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 OPI 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 TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE D 0, OWNER C L 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. LICENSE CLASS LIC. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION 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 POLICY NUMBER _ (THIS SECTION NEED NOT BECOMPLETED OF THE PERMIT IS FOR ONE FEB RED DOLLARS ($100)ORLESS). I CERTIFY THAT IN 1HE 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 3709 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 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND ERE: BY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED OPERTY FOR INSPECTION PURPOSES. EE N S T F ERMITTEE A E APPLICATION -) PERMIT (39 P/C DATE NUMBER # i ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET SIDE ^ PROPOSED USE L >T/ (x,47 c G-- NO. DWEL. 0. It, UNITS STORIE BEDROOMS DESCRIPTION SFR/ADD/REM Garage/Carport W Patio/Deck LL Pool/Spa Z Re -Roof 0 Commercial Ib -J U U W LU (D RW ^ SQ. FT Valuation UANTI DESCRIPTION FACTOR PSF ADJ.AREA FEE ADJ. AREA/VALUATION U W I ('Cl CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES /— J 7vh—/ (/ J I ./4t".1 L COMMENTS E' S/E / AAA. I,.uIJ— RECPT. NO. PAID Y VALIDATION WHITE -Department Copy, YELLOW -Finance Copy, PINK -Assessor Co ENROD-File Copy, GR N-Applicant's Copy OLD p 11