HomeMy WebLinkAbout13699 (14)I=
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 L. Copicy Drivc SLLitc 190
(909) 864-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 7 � •J
APN LOT TRACT
OWNER S f 1
ADDRESS-Z30if Sof C1/ F "7
CITY ZIP TEL. — /
APPLICANT �( (�. TEL. —�4
TRACTOR jtIl -r/U
CONOLAf�/ Cat/j�f
ADDRESS
CITY ZIP I�%q. TEL. _VjJft
ARCR'ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFF:FOA UNDER PENALTY OF PCFWnY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UWFON THE FOLLOWING REASON (SEG 7071.5 B;1S:NC55 440 PIL;F E$5ON5 CODE AW LITY OR
COLNrY W %cM RCOUIRE 5 A PERMIT TO CONSTflUCT.AL7ER W PRCVF- OCMOUSH. CR RE PARI ANY STTILIC-
TURE. PRIOR TO ITS ISSUANCE. ALSO RFOUIRES THE APPLICANT FOR SUCH PCFVAIT TU FILE A 5 GNED
STATEMENT THAI HE OR SHE IS UCCNSLO PURSUANT TO THC PROS-SIONS OF THE CONTRACTORS LF
CENSE UW (C1w TCR Y (COMM CNC N�TM SECTION 7000) OF ON L-0`. 7 OF THC 8:1514ESS AY7 PF!O-
VESSION S CODE) CR THAT HE OF S+IE IS EXEMPT THEREFROM AND THE BASS FOR THE ALLEGED EXEMP.
TION. AHY VXXATK)N OF SECTION 70]1.5 BY ANY APPLICANT FOR A PERMIT SURJECTS THE APPLICANT TO
A CfVL PENALTY OF NOT MORE THAN FIVE KINDRED DOLLARS
[I L ASOWNER OF THE PROPERTY .On MY EMPLOYEES WITH WAGES AS THC!R SOLE COMPENSATION.
WILL DO THE
WORK. AND THE STnUCTL'RC IS NOT INTENDED OR Orr[ RCD FOR SALE (SEC. 7041 BL' SI -
NESS ANo
PROFESSIONS COOL 7NC CONFRAC TORS LICENSE LOIN DOCS NOT APPLY TO AN OWNER OF
PROPERTY YW q BUILDS OR UPROVE 5 THEREON. AND WHO DOCS SUCH WORK 1•'M SELF CR HC RSC LF OR
TWRY
iOI HIS OR HER OWN EMPLOYEES. PROVIDED THAT S•JCMM W-ACVEMCNTS ARE NOT PI'E NDCD OR
OFFERED FOR SALE. F: FOWEVE R THE SLT,pNG OR:MPFIOVLIAL'NT 15 SOLD WITHIN ONE YEAR O C(MPLE-
TION. THE OWNER BU"LDER W U. HAVE THE BvnnrN OF PROVING THAT HE OR SHr 00 NOT BUILD OI
IMPROVE FOR Ta:PURPOSE Of SALE}
'JAS CW7:..R 0F7)'E PFIOPER-YAM EXCLUSWILY CONTRACTND W':TH t ICE. SE. C7N'MCTOfU
TO CONSTRUCT THE PRC:ECT MSEC 7944, BJSII.rSS ABX) PROFESSIONS CODE TH!' CA)N:RALTCRS LI-
CENSE UN DOES NOT APPLY TO AY OWSCR OF A PROPERTY W'Iq Bu=sOR W PROVES THE FE04 AVD
LIC
VOID CONTRACTS FOR SII PROJECTS WITH ADDSTHACTORIS) LICENSED PUPSUANT TO TME CON: RAC-
TORS
UGTORS LICENSE I AW I.
❑ IAM EXEMPT UNDER SCC B.SPC FCR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HFREBT AFF:RiM UNDER PENALTY OF PC'LR:R'• TMAT I AM LICF LASED LNDE R F RCV'SON'S CF CHAPTER
5 KXWAL NCNO W TH SECTION 7MC! O DTVISON S Cr THE BJS NESS A41 PNOrESS!ON S CCOE. AND
MY LICENSE 6 N^ FULL FOcCE AVD EFFECT.
LICE
DA EN,� COIRRACTOR���yf�i✓I
WORKERS' COMPENSATION DECLARATION
1 HEREBY Arnnu UNDER PENALTY OF PERJURY CNE OF THE FOLLCW -NG DECURATONS
_1 HA%E AND IVU MANTAJN ACEN:IFICATE Of CONSENT TO SCLF-INSOME FO'I W'URKCRS
COMIMSAT ION. AS PRNN'DED SY SECTION 1109 OF THE. LA'IFXT COCIE. FOR T•E PEPTORUANCF
OF THE WORK FOR WTMK71 TMS PEFPA.T IS ISSUED
1 HAVE AND WILL MAIN T AN W JRKCPS' COHPENSAISY/ INSURANCE. AS PCOE.' F113 BY SCCIION
5710OF THE LAfKNI COLE. FOIL 711C PERFORMANCE OF DT W OR4 To,. W7M f.H7.16 PERM:T IS
1551:ED. LAY WORKERS' CpMPTN'SA.ION FN 5: MANCE CARII•LR AW^, POLICY N::MO:R ME
CARRIER�,—
POLOYWJMV.-.Fi
(Tv4r Sr.CrICA+N'[Eo NCTC•E R.Y.ExrE--OF Tr C K., fi F.R.HLAMODOLNIS (S'x)O1 LES41
I DrY THAT IM THE PAN
ERrcrgMCE Or TIE WCAK FOR NANKIN TH: S PERMIT IS ISSUED. I
SRER:INOTE MPLOYANY PERSON N ANY M,NNFR SOAS TO RCCOME SIPULCT TO THE
VK)Mr RS' COMPENSATON LAMS OF CALIFDP.N A ANDAC:REE THAT IF I SKXILD BCOONC.
SUWECT TC THE WORI(ERi COIAPENSATION PPOW5UNS Cr SECTION 97)1) Of TI.E LABOR
CODC.I SHAG' :FM'TH COMPLY WITMT PRDVISOhS
DATE E_zg ARPLK:ANT
1
j 3UWEN^. FAAURC TO SECUREcn.w!N 1KERS' PENALTIES
ND TIONCrAL COVERAGE VP O ONE H WTLL. ANO SHAL BE
SVD.:E� AY EMPLOYER TO CR W NAL PENALTIES AND CML fF:CS UP TO ONE HUrtiRCO TFgUSAN:)
DOLLARS (710C.000). IN AOIO
D'TN TO THE COST OF COMP CN WION. DAMA5F S AS PROVIDED FOR IN
I SECTION 3. sor THE. LAaOn ttOC. IN -CREST, ANDATTORINCYS FEES
CONSTRUCTION LENDING AGENCY
i
FIE IMF. AFFIRMLANDSRPFTHE OPPFOR1AT'.UTTHEREISACONSTRL(SrC.LEND!NGC).
FON THE PERFORMANCE OF THE WORK FOR K)II:JI THIS PE RMIT IS ISSVL O ISR C. 0091, CIV C ).
LENDERS NAME
LENDER'S ADDRESS
I CERTIrY THAT I KRA READ TH:S APPLICATION AND STATE THAT THE A9C'.1 NF OfwA11ON 15 CORRECT.
1 AGREE TO COMPLY WI7H ILL CRY AND COUNTY ORD'NANCCS AND STATE LAWS PE LAWN TO BJRCING
CONS- RUC7ON. AND HEREBY AJTTOR:2E REP14ESENTATIVES OF TNIS COUNTY TO ENTER UPON THE
AMOVC Yi N: IDNI:o PROPERTY FOR INSPECTION PUnPOSCS
I PERMITTEE NAME (PRINT)
s TLD SX:NA7;IHL OF PEMMITTEC -� DArI
EXPIRED
DEC 0 71000 PRESS
FIRMLY
APPLICATION / 'PERMIT P/C
DATE NUMBER N
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RVI ❑
REAR ❑
SIDE/SIDE STREET RVI ❑
SIDE ❑
PROPOSED USE ✓I� i!f(IYr 1J/711I���i K ey10
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO FT. FACTOR PSF ADJ. AREA/VALUATION
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QUANTITY DESCRIPTION FEE
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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CO!lIACNTS �C '�7 V I
RECPT. NO.
PAID BY _SSS!" VALIDATION
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