HomeMy WebLinkAbout15147CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE c
ADDRESS?3S2C-235-38 .i�IJ`.�1t S{LICSaIs
APN LOT TRACT
OWNER OCtif- CrtL'r C!3PJ 4401 -
ADDRESS f-17 as r0C r"% -LL. I~ 10, LI
CITY ZIP4:t41f TELC)atY379-
APPLICANT TEL. 3 F S
CONTRACTQR C0 AoGFza:.
ADDRESS '1124 5 -
CITY
CITY Pos.O;J:- ZIFr E 21,L '-),- TEL(@.: 1) q"- 1412
ARCRTNG!
DESIGNER
ADDRESS
CITY ZIP TEL.
01NNER•BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY Or PERL:RY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOW'NG REASON (SEC 7031 S BJSNESS AND PROrEssCNS CODE. ANY CITY OR
COUNTYMIICH REOUTRIESAPERMRTO CONSTRUCT, ALTER IMPROVE. CCMOLISIL OR RCPA.R ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE. ALSO REOL21RES TIME APPLICANT FOR SUCH PERM T TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO TFL PROYSCfIS OF TIC CONTRAC70RS LI-
CENSE LAW ICT IAPTER 0 (OoMMCNCNO WITH sccroN 70MI Or D'VISION S OF THE BJS'NESS AND PRO-
FESSIONS [CCE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OFSECTION 7031.6 BY ANY APPLICANT FOR A PERM'T SUIL:EC75 THE APPLICANT TO
A C.'Y!LPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 1350¢)1'
OI.A; DWNCRO(THC PROPERTY.OR MY EMPL DYCCS WITH WAGES AS TICm SOLE COMPENSATION.
WILL DO TIE WON, AND THE STRLCmnc IS NOT INTENDED OR OFFEnrO FOR SALE (SEC. 7064. BUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN DW1ER OF
HO BUILDS On IMPROVES THEREON, AND WHO DOCS SUCH WORK HIMSE'J
PROPERTY WOR HE ASCLF OR
IO
TIUCH HIS OR HER OWN E MPLOYCES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED DR
CRFERED FOR SALE 6. HCMLYCR THC BULGING OR MI'ROYEMEN' IS SCID W! T HIY ONE YEAR OF COMPLE
TION, 114E OWNER BUILDER WILL HAVE TMC BLAZON OF PROVNR THAT HE OR SHE DO NOT B'J:LD OR
IMPROVE FORTHE PURPOSE OF SALE).
O LAS OWNER OF THE PPIOPERTY.AM EXCLUS VCLY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT TIE PROJECT (SEC. 70u, BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS I.I.
CENSC LAW DOES NOT APPLY TO AN CWNCR DR" A PROPERTY W!40 BJLCS OR IMF TIOVES THEREON. AND
WIOCONIRACTS FOR SUCH PROJECTS W:TIACONTRACTORISI LICENSED PURSUANT TOTE CONTRAG
TORS LICENSE LAN)
O IAM EXEMPT UNDER SEG 9 A PC. FDR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFrFM UNDER PENALTY OF FE RJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
6 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE sus%E55 mi()r RoriSSIOLE,NS COAND
MY LICENSE IS N FULL FORCES 1 AND EFFECT.
3
LICENSE CLASS C- LIC. NO y> L
DATE �•- Z t- -0 aA CONTrIACTOn C Sft
VIORKERS' CO,V.PENSATION DEC RATI
1 HEREBY AFFIRM LNDER PENALTY OF PERU'RY CNC OF CLLOW'NG
_I HAVE AND W LL MANTAN A CERT:r'CATE Or 'SENT TO SELF-INSL'n- OR WORKEi�
COMPENSATKk1,ASPROV•DL'DBYSECT 370o Or TIELA(H7R000c.ro1T7HEllciircRV
Or TIE WORK Fon WHK31 THIS PERMIT H 5SUED.
I HAVE AND W'LL MAINTAIN WOPKCRi' CCM'ENSATION R. SJRANCC. AS REOL7 BY SECTION
37o0 OF THE LABon Door.• FOR TIE PLRrORMANCE Or THE WORK FOR WN ,:I TH'S PEnMIT IS
ISSUED MYWOI:KEns,COMPENSATK)NINSLRiA\CCCARIIERMDPOLCYN_UDERME
CARRIER �[� _L_A W ^ IJ •t 11 1 .
POLICY
POLICY NI1L4Ir.R It -J, �-C , I
(neSSCCnCNDNOTBETCf
CM91 OrrCPEMC. Sren CNEWILIP O
N7:ECa FAR:,S1WICucss;
1 CEnTIrYTHAT N TIC PERronmk4CE OF THE WCPK FOR WILCII TI. PERMIT IS ISSOE0,1
SHALL NOT E14PLOY ANY PERSON IN ANY MANNER SOAS TO BECCM LL ECT TO T•r
WORKSPIT COMPENSATION LAW'S OF CF!IJFORMAL ANO ASR;'E THAT IF 1 S•Cly=mLCOMC
SUG:ECT TO THC WORKERS' OCAJPENSATION PIOV.SION!1 CF SCC1ON 3700 OF THE LABOR
CODE. 1 SMALL FCR: HWITH COMPLY W1711 THOSE PROV'SCNS
DATE. APPL?CANT.
WARN:NG rAILURE TO SECURE WORKERYCOMPENSATIDN COVERAGE IS UNLA'ATL"-AND SHALL BE
SL43JECT AN EMPLOYER TO CR:M'NAL PENALTIES AND CTRL FINES UP 70 DNC MJNDRrD THOUSAN'J
DOLLARS (I 100.0M). IN ADDITION TO THE COST OF COMPENSATION, DAMAC..ES AS PRCV!CED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTOME YS FEES
CONSTRUCTION LENDING AGENCY
I FIE RT.BY AFFIRM UNDER PENALTY Or PErUURY THAT THERE IS A CONSTFUCTION LENDING AGENCY
FOR THE PCnroAM^NCE OF THL WORK FOR Ve1ICH THIS PENAIT 15 ISSUE 0 (SCC. 3037, CN C).
LENDERS NAME
LENDERS ADDRESS
1 1 CERTIFY THAT 1 HR.'E READ THIS APPLICATION AND STATE THATTHC ABOVE IhrORMATKOH 15 tongCCT.
I AGREE TO COMPLY WnH ALL CI YAND COUNTY CRZ!NANCES AND STATE LAWS RELATN3 TO BULDING
CONSTRUCTOR. AND HEREBY AUTHORIZE RCPRESCNTATIVES OF THIS COUNTY TO ENTER UPON THE
AROVE MENTIONED PROPERTY FOR INSPECTION PURPOSES
IM3C0(IL.X-
L PERN:TTE N (PRINT)
i _ Q L.—:1 _u••
SIGNATURE OF PL• M;TTEC GAIL
APPLICATION /- a PERMIT �- l�� P/C
DATE (� NUMBER M
ISSUETYPE occ
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(0 �'? �/ `�
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
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PROPRSEDUSE Ct1--OOF Gn.2a1G� �(o^ 12-0,1 -.
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NO. DWEL, NO. NO.
UNITS STORIES ( BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION
SFR'ADD,'REPA
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QUANTITY DESCRIPTION FEE
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ENERGY PERMIT T'tir 0' IJ•• " .V) S:•.L A� -
RETENTION FCC: - �L11?1 L •
PRE -ALT FEE:
TOTAL FEES.
COMMENTS
RCCPT. NO. PAID BY
I VALIDATION
WHITE-Oeparlmert Copy. YELLOW-I'marKw Copy, PINK -Assessor Copy. GOLDENROD-FIk/ Copy, GREEN-Applicanl's Copy
CITY OF DIAMOND BAR -
INSPECTION RECORD
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