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Home My WebLink About15062 (34)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 BUILDING PERMIT APPLICATION JOBSITE ADDRESS (� W APN LOT TRACT OWNER A ADD SS CITY iiFUjTEL. % A APPLICANT topTEL. CONTRACTOR ADDRESS CITY ZIP TEL ARCK/ENG! + DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AMEXEMPT FROM THE CONTRACTORS U - CENSE LAW FORTHE FOLLOWING REASON (SEC.7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTYWHCH REOUNESA PERAITTOCONSTRUCLALTER. IMPROVE, DEMOLISH. OR REPAIRANY STRUC- TURE, PRIOR TO ITS ISSUANCE. ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE M UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS COW ORm1AT HE OR SHE IS EXEMPT THEREFROMAND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70 A NALTY OF NOT MORE THAN FIVE HUNDRED DOLENS (9500),I: A5 OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, YFI THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE IS EC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS 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 ED OFFERFOR SALE IF HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE- TION, THE OWNER43UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BURR OR IMPROVE FOR THE PURPOSE OF SALE). D L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WIN UCENSED CONTRACTORS TO CONSTRUCT THE PROJECT ISEC. 70", BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND VA4000NTRACTS FORSUCH PROJECTS WITH ACONTRACTORIS) LICENSED PURSUMRTO THE CONTRAC, TORS UCENSE LAW.). D I AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON LATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT J AM LICENSED UNDER PROVISIONS OF CHAPTER S (COMMENCING WITH SECTION 7000) OF DIVISION 3 O 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 37000E 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 (RIS SECTION M®MOT BE COMPLETEDOFTFE PERM IS FORONEHUNDREDCOLLARs (WO)OA LESS), 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT O ISSUED, I I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE j WIORKERS'COMPENSATI7N LAWS OF CAUFORN IA. AND AGREE THAT IF I SHOULD SEOOME SUBJECT TO THE WORKERS' COMPENSATKJN PROVISIONS OF SECTION 370D OF THE LABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. 1 I DATE: APPLICANT. e WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TOONE HUNDRED THOUSAND DOLLARS I" 00.0W], N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN 1 SECTION 3708 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES. N CONSTRUCTION LENDING AGENCY i I OR THE' AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY.). FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC. 7007, CIV C.). I LENDER'S NAME LENDERSADDRESS 1 CERTIFYTHAT 1 HAVE READ THIS APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULDING s CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO EWER UPON THE ABOVENAENTIONED PERTY FOR INSPECTION PURPOSES. j s P rrrEE (PRI C BIG NA PE ITTEE DATE PRESS FIRMLY APPLICATIO! iir7 PERMIT DATE / (/ �/ NUMBER i k ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE o Co ul NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREWALUATION SFR/ADD/REM cr) Garaga/Carporl W Patio/Deck PooVSpa ZRe -Roof Commercial In Valuation ADJ.AREA QUANTITY DESCRIPTION FEE ¢rU V W J w 0 Z flO J a - z 2 Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE ✓ — `� SMTP + ENERGY P/C t11� r'1 ENERGY PERMIT T BAR f.f AY 1 " RETENTION FEE: v PRE -ALT FEE: :31,111, N I-� ✓ t L. ' TOTAL FEES COMMENTS RECPT. NO, PAID BY 4 VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy A