HomeMy WebLinkAbout15161 (17)UI,IJII)\U I1AK
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
/ BUILDING PERMIT APPLIC),
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JOBSITE 00 -�O
DATE CONST. GROUP
ADDRESS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
APN LOT TRACT
PROPOSED USE
OWNER 64 G
UNITS STORIES BEDROOMS
ADDRESS / 'Y tG
DESCRIPTION SO. FT FACTOR PSF ADJ. AREA/VALUATION
CITY TEL. 9.1'6'(YT Y4k4
SFR/ADD/REM
APPLICANT TEL.
Garage/Carport
CONTRACTOR
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ADDRESS
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CITY ZIP TEL .S
Pool/Sps
ARCWENG/
-Roof 1
DESIGNER
Commercial
ADDRESS
CITY ZIP TEL.
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OWNER -BUILDER DECLARATION
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QUANTITY DESCRIPTION FEE
I NER®Y AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U•
CENSE LAWFOR THEFOLLOWING REASON (SEC. 7091.6 BUSINESS AND PROFESSIONS GODE: ANY CITY OR
OMWNM*MREOLARESAPERMrTTO CONSTRUCT,ALTER IMPROVE DEMOLISH, CR REPAIR ANYSTRUC-
TURF 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 U•
CENSE LAW (CHAPTERS(COMMENCING WITH SECTION 700D1 OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS OWE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE SASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7001.6 BY ANY APPLICANT FON A PERMIT SUBJECTS THE APPLICANT TO
OO
A CML PENALTY OF NOT MORE THAN FINE HUNDRED DOLLARS (66001.):
L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COMPENSATION,
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WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70M• BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF
PROPERTYWHOBUEDS OR &PROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN CH EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FORSALE IF HOWEVER THE BUILDING OR IMPROVEMENT 18 SOLD WITHIN ONEYE'AROFOOMPLE-
TON, THE OWNERaUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
OLASOWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70" BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
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CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
CONSTRUCTION V
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOP(S) LICENSED PURSUANT TO THE CCNTRAC.
PIAN REVIEW
TORS LICENSE LAW).
ELECTRIC
O 1 AM EXEMPT UNDER SEC. B. 6 P.C. FOR THIS REASON
L=
DATE OWNER
MECHANICAL
LICENSED CONTRACTORS DECLARATION
2
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
ISSUANCE
e (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND
SMIP 2i,: U lfl
MY LICENSE 18 N FULL FORCE AND EFFECT.
0
LICENSE CLASS I UC. NO.
ENERGY PERMIT T. r I` T• ' T
DATE AC Ob & CONTRACTOR
RETENTION FEE:
WORKERS' COMPENSATION DECLARATION
to
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1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE -0 WILL MAINTAIN A CERTIFICATE OF CONSENT TO 8ELP4NSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT W ISSUED.
COMMENTS
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
04
8700 OF THE LABOR CODE• R THE PERFORMANCE OF THE WORKED HIGH THIS PERMIT IS
ISSUED. MY WORKERS' MR AND NUMBERARE:
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CARRIER F
POLICYNUMBER 1.5
CMSCCTIGNNELDNDTBECOOLOMOFT EPERMRBFDRCNEHLAOREDDouAFLsmaaGRLW
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1
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SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
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WORKERS'COMPENSATOAWS N LAWS CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUILIECT TD THE WORKERS' COMPENSATION ROVISIONS OF SECT H 700 OF THE LABOR
S
CODE, I SHALL FORTHWITH COMPLY WITH SE PROVISIONS.
2 r2
p
DATE: ` APPLICANr.
WARNING: FAILURE TO SECURE WORKERS'COMPENSATON COVE RA IS UNLAWFUL• AND SHALL BE
TO
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U TOONE HUNDRED THOUSAND
DOLLARS (6100.00D). IN TO THE 0087 OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
JSECTION
3700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
4
25d
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
Fu
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
LENDERS NAME
LENDERS ADDRESS
C
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THEASOVE NFORMATON IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCESAND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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SONA I EE DATE
TION
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PRESS
FIRMLY
APPLICATION 7•{ s PERMIT
1 1 P/C
DATE NUMBER #t
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ISSUE TYPE OCC
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DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
U)
Garage/Carport
W
Patb/Deck
LL
Pool/Sps
ZRe
-Roof 1
0
Commercial
I9
Valuation u V Lo,ADJ.AREA
QUANTITY DESCRIPTION FEE
U_
L)
Lu
J
W
Z
Im
CL
CL
4
U
Z
2
W
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CONSTRUCTION V
PIAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP 2i,: U lfl
ENERGY P/C �_'y�"_ `
ENERGY PERMIT T. r I` T• ' T
RETENTION FEE:
PRE -ALT FEE: A.
TOTAL FEES i J7 0
COMMENTS
RECPT. NO. PAID BY VALIDATION
WHITE --Department Copy, YELLOW --Finan Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy
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