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Home My WebLink About14098 1 �y,�.;\A CITY OF DIAMOND B AR \�� DEFARTMENT OF COMMT.TNITY dc DEVELOPMENT SERVICES Zl�so�.cop�y�ive suic�l90 PRESS (909)860-3195 Fax(909)861-3117 .A �'��" BUII.TIING PERMTT APPLICATION FIRMLY � J08S1TE / ,/ -y APPUCATION PERMIT � �� P/C C � ADDRESSL�`C-B �LC�$� �1 ' DATE�-��-"��. NUMBER �: # ! -- g I5SUE TYPE OGC � APN LQT TRAGT DATE CONST. GROUP � � OWNER C{"I��_ _ p AODRESS ZONING SETBACKS w CITY _ ZIP TE�. REART RW ❑a APP�ICANT TEL. SIDEtSIdE STREET _ RW ❑ CONTRACTOR�� +�al..- SIDE �_� g ADpRESS S+ I , CITY D Z(p�/pp TE PROPQSED USE�e 6 �a ARCH/ENG/ dESlGNER NO.DWEL. NO. NO. ADDRE5S (��jS ST4RIES _ BEdRQOM5 � ciiv ZIP TEL. cn dESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION gFRJAD0IREM O I HEREBY AFFlRM UNDER VENALTY OF PE WURV THAT I AM EXEMPT FROM TME CbNTRACTORS LI- G2feJe(Cdf�lOft W CENSELAWFORTHEFOLLOWIN�RFA�ON{SEC.T0.3t.58U51lfES5ANDPFiofES5roN5GODE:ANYGtTYUR (� , Z TU�q�qR TO TS I 9VM1Cf.ALSA REQU RES THE APPLICANT�FOR SUUCHi PERMIT TO FIL�5 GNED w P3�i0/DBCk �� 3TATEMENT THAT HE OR SHE iS LiCEN5E0 PURSUANT TO TFiE Fi�Vi5ION5�THE C�M1iTRAG7OR5 i.i- W CEN6E lAW�CHApTER Y(COMMENCiNO WITH SECTpN 706U)bF DIYISION 3 4FTME BUSINESS AND PPO- V' P001/${?2 �, 6oa� FESSIONSWOE)ORTMATMEOFSHEISFJ(EMPTTMEflEFROMANDTHEBASISFOR7HEALlEOEDEXEMP� (� TIOti.M1Y VM)LAtKJN#SECTKKi T451.5 8Y hNY JiPPIICANT FOR A PERFi7F SU&IECTS TH6 APPUGANT T0 � Re-Roof � A CIVIL PENAITY QF NOT MORE THAN FIVE HUNDRED DOLUR5(SSoo).); � ❑I,ASONMEROFTHEPFlQPERtt.�RMYEMPIOYEESwITNWA6ESASTHE1R90LECAMPEH5A71pN, C� �p{nm8tCi2I WR.I DO T}iE WOAIC,AtM7 TNE STRUCSURE iS NbT iNTEN6ED OR OFFERED FOii SRLE�SEC.�OM,BU54 J � NE55 M1D Pf10FE5510NS COUE:THE CONTMCTORS LICENSE I.AW DOES NOT APPLV TO AN OWNER OF � PROPERTY Nkq BVNDS OR IMPR4YE5 TtiEttEIXi,AND WMa DOE5 SUCN 4MOflN MIMSELF OR HERSEIF OR (r TMN{%X3N HIS OR HER OWN EMPLOYEES,PROVIOED 7MAT SUCFI iMPqpVEMENTS ARE NOT INTEN�ED OR m l�1 OFFERED KOH SKE IF,11qWEVEi�TH6 BUILOING Ofl IMPHOVEM@!T IS$OLD WITHINONE YEAFOf COMPIE �..�� TiOM,Tff OWNERAUIIREft WILL F4lVE 711E BURpEN OF PROVIN6 THAT FfE OR SHE 610 N07 8t3t[D pfl � IMPRDVE FQR THE PUR705E QF SN.E). ❑1,AS OMMER OF THE PflOPERTV,AM EXCLUSIVELY CONTMCTING WITH IICENSED CONTRAGTOR9 � 70 CpN53RUCT Tt�PFtQiEC?(�C.JOLt,HU3INES5 AND PApFESSiONS CODE:THE fRNiMCTOFS 4i� V21UBI14fl ADJ,AREA _ CEN9E UW OOE$NOTAPPLV 70AN 4lWNER OFAPROPBRT�'WMO BUILDS OR IMPqpVE3 THEREON,AND NTIOCONTMCTSFORSUCHPROJ£CTSWf7HAC6NTMCTOq{5�UCENSEDPURSUANTT4THECdNFflAC- {}UANTITY OESCR7PTIQN FEE � TORS i7CEN5E UW.}. t *� - �i AM EXEMPT tA:DER SEG. B.E P.C.F4R THIS REASON Q [ +G �� c> ,r.��'} �)�� LL DATE GIWNER� LL L.,• �` .LF"` l5 i t„� � ~ �.. L � U q I.ICENSED CONTRAGTORS DEClARA7ION W J � lT W �� l-' f !HEREBY�FFIRM UNOEft RENALTY Of AERJURY THAT t AM UCENSED VNDER PftOV15lONS RF CHAFTEfl � � � V r � � 9{COMMENCNI(3 WITN ScCT�Oq�bob)OF DIVISION 30F THE 6USINESS AND PROFESSiON9 CODE,AND z � � X AAY LICENS6IS IN FULL FQRCE AND EFFECT. � � + �« �j/��{ .�a � ��. � LICENSECLASS C�� LIC.NO, �L 9 /�� - ,y ♦f �/ � V DATE 7'i^� •� CONTRACTOR ��^!� I=Ir'7 a W +� WORKERS'COMPENSATIC7N DECIARATIC?N a � t HEREBY AFF#iM t#aDER PENAtJY OF PEFUVAY ONE 6FTHE FOI.L4WING DECLARATIONS: Z C..S.] ^IMAYEANDWILLMAMITAIkACERTIFICATE')FCbNSENTTOSEIF-INSUHEFQRWOflKERS' _ � CQMPfNSATKKi.AS PR6VIOf.4 8V 5ECTION 3'lOOOFTH6lA80R COCE,FOfl THE PEflWRMRNGE �U OF 7HE WQRK FtlR WNICH TNIS PERMIi IS ISSUED. � n � _„„_I HAVE AHp WILL IMINTAIN WQRKERS'COMPeNSATION INSURANCF,AS REOLIIREO BV SECTION /j � � a7000FTHELA50RCO0E.FpRTHERERFORMANCEnFTHEWQRKFOPWNICHTHI5AERMITiS `.� * �r{. . tSSUEb.i.tV YAflKF_RS'COMPENSATiDN iN&UftnNCE CARR�ER AND P6LiCY NUMBEfl ARE: CONSTflUCTION _ y� c�qqiErt G , , PtAN REVIEW � C? POI.ICY NUMSEH 1T�I �� '?i _�_..._ ELECTRIC __ f ° ,��- (iNkssft:rqnrvEkor+o7BEml.wt�FDOFrr1EaERMrsFOaadEHUH)ItEom.u�ns(5ico)oa�Essa PLUM6ING � � �),�y,�:-}r-� � ICERTIFY THAT IN TNE P£RfOflMANCE OF TNE WdAS{FOR WH�CH TN5 PERMIT IS ISSUEp,I MECHANICAL __ 7"��'.:(.� (� SHALL NOT EMPLQY ANV PEF30N IN ANY MANNE%SO A$TO 9EGOME SU&IEGT TO THE � � (/} WGfKKERS'COMPEtiSATiON IAWS OP CA1tfORNiA.AN6A6REE THAT!F i SFN)U�p BEC4ME (NSPEGTIOFI FEE _ -� " . y:.�� SV&lECT T6 THE wORKERS'COMPEN5NT10N PROVISIONS OF SECTIQN 3]00 Of THE UBCiR - "� � � COOE, 5HALL FpRT1iWITH CpMPLY WI7M THO E PROVISION$. �SSUANCE • ..� � �'� _ ..._, ,.,__..._. �_ � � ��y �.2 ` SMIP � ,. ._ ___1_'__LS... p DATE: ""1..� APPLICANT: _ _ F � WARNIH6:FNIURE TO SECUflE WORKERS'C;OMPENSATION fAYE AGE IS UNIAWFU4.ANp SHALL BE E{VERGY P/G „ ,,,,,,� _ LL SUB,IECTANEMPLOVERTOCRIMINALPENAl,71E5ANDCIVILFINE5UP700NEHUNORE�THOUSAND ENERGYPERMIT DIXlARS(ii oa.aWi.�N ADDiTKNi TO THE C65T OF COMPENSA7Nk�7,DAMAGES AS PRONDE6 F�rR iN / � SECTpN 3708 OF THE UfiOR CODE.MTEREST.AND ATTORNEI^S FEE5. RETENTION FEE: '� 4� ..� .._ .__ .....__— 6�_. CONSTAUCTION LENOING AGENCY PRE-AL7 FEE: �� O — -" C� �MEA66YAFFiFM tM�EA PENALTY OF FEftJVRY TMAT THEftE 15 ACONSTRUCTION I.ENDFNG AGENCY � _ fOR THE PGRFORMANCE OF TN6 WORK FOR WHICH THIS PEflM1T IS ISSUED(SEC.3087,CIV.C.). Z LLl � LENbER'S NAME F`s 4ENDER'SAL70ftESS _ „__. `i ICERTtFY7NATINAVFAEADTtiiSAPPIiC.i710NANDSTATETttATTHEABDVEINFORMATpNlSC6RRECT. T�TAL FECJ �� " �'_3 � /��1, � I AGREE TO COMPLY WITH ALL CITYlW�COUNTY ORDINANCES ANO STATE LAWS RELATING TO BUILOING �� - � � � � CONSTRUCTION,AN�HEREBYAUTHOFiREftEPRESENTATIYESOFTHISCWNTYTOEMERUPONTHE S� ABOVE-MENTXN7ED F�PERTYFORtNSPECTI6NPUPPQSES. CCIMMENTS b � 'E'i!l//J tJ� '� PERMI7TEE NAME P � ,,,�,,, 4 q _ ,� r /\`.__i.'7�� 3' � ( .--"" i Uy SIGNATURE OF P£ EE f D E � �'� _ � f, � RECPt NO. -�' �PAID BY ✓"� VALIDATIqN WHITE--•Qepartrt�erat Copy,YEI.L4W—Fptanc6 Copy,PINK—Assessor Copy,GOIDENRpO—Fi(e Capy,GREEN—Applicant's Copy �*�`�"�" �.�� .n �� a �,;,` �� `=��: ��,�� '��,� �� ,.��, � �> . � _a � � „.. ' �� ''��'x�� - � � °�� `. � _ _ � � _ , , � . � ..___ _. ., - ._ _ . � �: �_ . � � . _ _ =� . � � ° � _ __ : .. � , .,, � . :;, _ - - � , �� , . � , ,. _ _ _ , ,..�. .� �� ,� ,� .��z. , _ ._ , � ,�=f. � �� . . _ � �� ,,. �� _ _ , . . _ _ � _ _ _ ._-- _ . , , ,�, � y=� � � - _ . _ �y � __.___ _ _�. _ _ ��; �, , - �� 4 =�� i�-2Y._� _�. �.� . _ _ _�.. _ . _ �- �. _ __ � ._ � . . G �� . _ - „ . . �,,.t _ ct_ . . . � �� _ _ _ _ ___ _ __ �� - � �u- -_, _._ _ _. _ . ._ _ ,�__� _ _._. . _ _ . r r ..t....1r � � i , � � � � . � . -.� �',�= .. � � i� � � .� _ _ .. . _�_ /�� . . _ "4 _ .. _. _ _ _ _ � ( ' : .,. ,�.. � r - �'O U� -'L'{^ k ..._ _ , _�� . _ r . >u� � � , :_ g ti w , . � . .�,,�„�,�.�.� ��.�� M. . , •� ,.. r ;k . . x !n'x! � � �i�4 �? e%,� _ ; �e �-�� v � �� ' '�3G _ _ � � .ar�t14 .: '1; :"il,,`•'!��+'�, : � :_T� ��.. as�,��,a ... .., _ . _ _ ; , _.,"�.".�-1��. _ _ _., __ _ _ _ _ _ _ _ . _., __ _ _ _ _ _ __ _ _ �,av , �� 4:. ��>��r g A.,t� _ _ �'�' ;�� • � ' , " ., � � � �+ti`� .� , i __ _ _ _ � � � , � �� .� � �� ;.,�; �� . , : _._ _ __ . _ �t ,. , , � 't �� y; � � �, _ _ � ,k�, �, , `;� " �,t; � � _ �� , ,. _ �� , n�� _ _ _ ., . � � �� r�� ' - ,.. a .. _ ' , �,., __ _ ,.s . ; � � � . �� ,�• � r �r��,,..�.- �.�� _ _ _ � I CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21660 E.Copiey Drive Suite 190 (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRM�Y 15 I ADDRESS APN LO T TRACT OWNER-�1 - ADDRESS CITY ZIP TE�. APPLICANT TE�. CONTRACTOR a a L ADDRESS CITY D ZIP 00 6 TE ARCH/ENGJ DESIGNER ADDRESS CITY ZIP TE�. OWNER-BUI�DER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE�AW FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRESAPERMITfO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC. TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI- CENSE IAW(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 A�LEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DO��ARS(5500).): ^ 1,AS OWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION, WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SAI.E(SEC. 7044, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE�AW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUI�DS 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 SO�D WITHIN ONE YEAROF COMPLE- TXki.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ l,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE t_AW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PRO)ECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS UCENSE lAW.). ^I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DEC�ARATION I HEREBY AFFIRM UNDER PENA�TY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH S2CTI,ON 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND MY�ICENSE IS IN FUL�FORCE AND EFFECT. 9/�/Jn LICENSE CUSS G53 LIC LDI NO DATE 4�-3 CONTRACTOR(l� WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS: I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t.ABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE. CARRIER-C POLICY HUMBER RHIS SECTION NEW NOT BE OXAW�ErEDOFTHE PEFMT IS FOR ONE HUNDRED DOLIARS($100)OR�ESS} I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHAL�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(ABOR CODE,SHA�L FORTHWITH COMPLY WITH THOSE PROVISIONS. / DATE:APP�ICANT: --lJ( � - �--IN WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVE AGE IS UN�AWFUL,AND SHA��BE SUBJECI'AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�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 I.ABOR CODE. INTEREST.AND Al�'ORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENA�TY OF PER]URY 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 I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�,4WS RE�ATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE'MENTIONED ROPERTY FOR INSPECTION PURPOSES. NN f nl PERMIITEE NAME PRINT� SIGNATURE OF PE EE DATE APPLICATION PERMIT ' P/C DATE d-��'I #/ .. ,NUMBER ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ^ REAR ^ SIDE/SIDE STREET RW ^ SIDE ^ ,r PROPOSED USE u e O N0. DWE��N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. Ff. FACTOR PSF ADJ.AREANA�UATION SFR/ADD/REM U) Garage/Carport LU Patio/Deck L LL Pool/Spa 6 Z Re-Roof 0 Commercial D Valuation ,ADJ.AREA QUANTITY DESCRIPTION FEE a U W a L 65 �_ W }. U -sT�A ea Z I <1 2 U W 9 M AM 4 9 B�MM - f 2 CONSTRUCTION PLAN REVIEW E�ECTRIC P�UMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY PJC ENERGY PERMIT RETENTION FEE: .j(-' PRE-ALT FEE: TOTA�FEES COMMENTS RECPT. NO./PAID BY/'°-j VALIDATION WHITE-Department Copy,YE�LOW--Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy --Q4-Ir)