HomeMy WebLinkAbout18898 ___1,�;r�__ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Ftle Copy,GREEN—Applicant s Copy
CTTY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
APPLICATION
DATE
/0/./. ,,, PERMIT 013/C 02_t'9/'
1094---NUMBER
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
0
N0. PROPOSED
UNITS
USE
DWEL. ifie6i7 v-54/ 13362_
N0. N0.
STORIES BEDROOMS
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111
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SFR/ADD/REM
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QUANTITY DESCRIPTION FEE
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TOTAL FEES 3„ZPOZ,'-Z2 t) 3 6/ 14
COMMENTS
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RECPT. N0. PAID BY (-1("/3 VALIDATION
JOBSITE ADDRESS
650 sic)/LI'ive
DATE
PRESS FIRMLY
APN L T TRACT OWNER
ADDRESS .72P.V5211111WWWMEACV crry 1414/NA.-t--- ZIP „,
/7I TEL.
APPLICANT TEL.
CONTRACTOR fre-_-;Ao cc)Zue.ADDRESS
CITY
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP
TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE
FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE.ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO
CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUCTURE,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 LICENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND
PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMPTION ANY
VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT
MORE THAN FIVE HUNDRED DOLLARS(8500))
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COMPENSATION,WILL DO THE WORK,
AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSINESS 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 H/S OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS
ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF
COMPLETION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR
THE PURPOSE OF SALE).
0 I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE
PROJECT(SEC 7044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER
OF A PROPERTY WHO BUILDS OR/MPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)
LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW).
0 I AM EXEMPT UNDER SEC B.&P C FOR THIS REASON
SIGNATURE OF PERMITTEE
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH
SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT.
LIC N0. 7 01...-7fr-7
CONTRACTOR A-;44:5„--A•co 64---<
WORKERS'COMPENSATION DECLARATION
LICENSE CLASS DATE
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATICNS
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.
41 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF 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
(1HISSEC110N NEED NOT BE COMPLETEDOF THE PERMIT IS FOR ONE HUNDRED COLLARS(3103)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL 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 LABOR CODE,I IALL
FORTHWITH COMPLY WITH 7pSE PROVISIONS.
DATE: APPLICANT A.4..."...r.,9jvc.
WARNING AILURE TO SECURE WORKERS'COMPENSATION COVERAE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU_ARS($109,000),IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY 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 COMPLY
WITH ALL CITY AND COUNTY ORDINANCES AND 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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DATE
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