HomeMy WebLinkAbout13252 (27)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
- 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 86173117
A BUILDING PERMIT APPLICATION.
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ISSUE 1r TYPE OCC
APN LOI TRACT 3-94100
OWNER (D _
ADDRESS -
CnT.1105MOEMZIP EL.
APPLICANT TEL.
CONTRACTOR G
ADDR S
CITY 8.3 • ZIP > TEL.
ARCH/ENG/ '
DESIGNER .,
ADDRESS
CITY ZIP TEL.
6WNER•BUILDERDECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (BED.7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTYWHICHREQUIRESAPERMTTTOCONSTRUCT„ALTER IMPROVE, DEMOLISH,ORREPAIRANY$TRUC-
” TUBE, PRIOR TO ITS. ISSUANCE, �L50 REOUiRESTHE APPLICANT FOR SUCH PERMIT TO FILE SIGNED
STATEMENT THAT HE OR SHE IS LICER$ED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER 8 (COMM NCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSION$C=ORTHATMED SHE 1$EXEMPTTHEREFROMAND THE BASIS FOR THEALLEGEDEXEMP-
TION.ANYVIOLATIONOFSEC'n 7031.5 BY ANY APPLICANT FOR A' PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE 11HAN FIVE HUNDRED'DOLIARS ($600).):
D I,ASOWNEROFTHEPRO E -TY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
..WILL DO THE. WORK AND THE 5 .UCTURE.ISINOT 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 BUILDSORIM OVES7HEREON,,AND WHO DOES SUCH WORKRMSELFOR HERSELFOR
THROUGH HIS OR HEROWN EMP 0' ES, PROVIDED TFIATSUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFER EDFORSALEIF,HOWEVE THE BUILDING OR'IMPROVEMENT ISSOLDWITHIN ONEYEAROFCOMPLE-
TION, THE OWNER -BUILDER WI HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF ALE).
❑ 1 AS OWNER OF THE PRO�ERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRA RS
TO CONSTRUCT THE PROJECT ( EC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOESNOT APPLY TOAN.OWNEROFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PR ECTSWITHACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC-
7ORS LICENSE LAW.).
D (AM EXEMPT UNDER SECT B. & P.C. FOR THIS REASON
`
DATE ._ OWNER,
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENAL 'OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING.WITH SECTION OF DIVISION:a;OFTHE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS AV FULL FORCE D EECT.
LICENSE C(ASS LIC, NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PE NAL OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
_IHAVEANDWILL MA'NTAI ACER7IFICATE OF CONSENT TO SELF -INSURE FORWOPKERS'
COMPENSATION, AS PRO IDED BY SECTION 3700 OFTHE LABOR CODE, FOR THE PERFORMANCE
OFTHE WORK FOR WHIC THIS PERMIT IS ISSUED.
i HAVE ANO WILL MAINi(LI WORKERSCOMPENSATION INSURANCE, AS REQUIRED BY SECTION
37000E THE LABOR COD E.PERFDRMANCE OFTHE WORK FOR WHICH THIS PERMIT IS
,FORTH
ISSUED. MY OR M,ENSATI IN URANCE CARRIER AND POLI YNUMBERARE:
CARRIERAt
m
PQLICYNUMBER
(THIS SECIIONNEEDNDTR,,
CI OFTHE 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
SHIALL NOT EMPLOY ANY
WORkERS' COMPENSA7I
BU ECTTO THEWORKE
PERSON IN ANY MANNER BOAS TO BECOME SUBJECT TO THE
N LAWS OF CALIFORNIA,ANDAGR THATIFIS IILDBE ME
"COMP ON mu IS- SET 00 FjH R
is FOP7HWIT
Cq 7 S NS I/✓°/"?
DATE: A
PLIC -
RKERS'COMPENS N COVERAGE IS UNLAWFUL, AND SHALLBE
HI;PENAf,TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
WARNING:. FAILURE TO SEOUFjE
". SUBJECT AN EMPI.OYERTq CIiIMI
" DOLLARS (6100,000), IN ADOITI
0 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR
, INTER EST, AND ATTORNEY'S FEES.
CISTRUCTION LENDING AGENCY
i
I HEREBYAFFIRM: UNDER PENAL IOFppER.IIIPYTHATTHERE IS A CONSTRUCTION LENDING AGENCY
" FORTHE PERFORMANCE OF THE ORIC FQ<S WHICH 'HIS PERMIT IS ISSUED (SEC. 3097, CIV. C.).
I
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READTHISApjiLICAT)pN;'AND STATE THATTHEABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALt, CI ANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION AND HEREBY AU ORIZEREP ESENTATIVESOFTHISCOUNTVTOENTERUFONTHE
ABOVE- MENTIONED PROPS ROW OS(�LE�S.
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SIGNATUR EE 1) E
PRESS
FIRMLY
APPLICATION PERMITP/C
DATE NUMBER_. #
ISSUE 1r TYPE OCC
-1_
DATE LlJ CONST GROUP
ZONING SETBACKS
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REAR Ej
SIDE/SIDE STREET RW q
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO. -
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ: AREA/VALUATION
SFR/ADD/REM
CD
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WPatio/Deck
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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INSPECTION FEE _
ISSUANCE
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ENERGY P/C
ENERGY PERMITy
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES °
COMMENTS
RECPT. NO. PAID BY VALIDA710N
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