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Home My WebLink About11035— CITY OF DIAMOND BAR L COMMUNI'T'Y DEVELOPMENT DFPARTMFNT 21660 E. Copley Drive Suite 190 ;� (909) 860-3195 Fax (909) 961-3117 "' rsLf�/ryt/ BUILDING PERMIT APPLICATION JOBSITE ADDRESS APNLOTS TRACT,_-___-_._._„_ OWNER ADDRESS CITY ZIP TEL. APPLICANT TEL. CONTRALTO �i cc art i..--_,_. ADDRESS . r- 1C, 4C CITY FlACrCK'blid-e_ ZIP ZS�fs I TEL. V* ARCH/ENG/ �, DESIGNER ADDRESS l ✓(a CITY _ .-.. _. _.A4-__ ZIP---- TEi - OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PEHJUHY IIIAT I AM EXEMPT FROM IIID CONI RACTORS LI- CENSE 1.AW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS COUE. ANY CITY OR COUNTY WHICT l REQUIRES A PERMIT IO CONST LUC1, ALT ER, IMPROVE, DEMOL ISH, OR RFPAIn ANY STRDC- TUBE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES 1'HE APPLICAM FOR SUCH PFRMIT TO FILE A SIGNED STATEMPNI PHAr HE OR SHL IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI. CENSE LAW (CHAPTER 9 (COMMENCING WITH SCC I ION 7000) OF: DIVISION 3 O IRT. BUSINESS AND PRO PF.SS:ONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR TI IS ALLEGED EXEW TION. ANY VIOL AT ION OF 5ECTIO.N 70315 BY ANY APPLGAN I FOR A PLRMII SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SOOI.j L7 I, AS OW NFI{O1 I I IL PROPERTY, OR My EMPI OYFFS WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND IFIE 51 RUCTURE IS NOT INTENDED OR OF FERED FOR SALE (SEC. 1044, L3USI- NESS ANO PROFk3SSIONS CODE. THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERI Y WHO BUILDS OTT IMPROV613 THk:HFCN, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCI i IMPROVEMENTS ARE NOT INTENDED OR OFFEREDFORSAI _ II',HOWL-VER,THEBUILDING ORIMPROVEMENTISSOLD WITHIN ONE YEAROFCOMPLE- TION, THE OWNER BUILDER WILL HAVE: THF BURDEN OF PROVING THAT HE. OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 0 I, AS OWNER OF I TIE PROPERTY, ALI FXCLUSIVELY CONTRACTING' WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CON TRACTORS U. I AW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS On IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJLC FS WR I I A GONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). I I i AM EXEMPT UNDER SEC. __- ..-- B. & P.C. FOR THIS REASON DATE ---------"'— - "'----- OWNEA.--- LICENSED CONTRACTORS DECLARATION HEREBY AFFiRM UNDER PENALTY OF PERJURY THAI IAM LICENSED UNDER PROVISIONS OF CHAPTF,R 9(COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PP.OFESSIO, CODE, AND MY LICENSE 15 IN FULL F( VD CFFECI 1'� LICENSE CLASS _ , 10 LIC. NO. ✓ N DATE I Z f! a Yw CONTRACTOR : 40Q�004�!„ WORKERS' COMPENSATION DECLARATION HEREBY I AFFIRM U.NDFR PENALTY OF PERJURY ONE OF THE FOLLOWING DFCL ARATI0 S I ANL) WIL IMAINTAIN A CERTIFICATE OF CONSENT 10 SELF-INSURF FOR WORKER`, COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WI ITCH THIS PERMIT IS ISSUED. ------ I HAVE AND WILL MAINTAIN NIOHKLRYCOM,PENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR TI IE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INNFYRANCE CARRIER AND POLICY NUMBER ARE: CARRIER_571 POLICY NUMBER ;5.f. I�:L._ L� (THIS 5EGFON NEED Nor HE OGMPLh i ED OFTHE PERMIT IS FORONE HUNDRED DOLLARS (5100) UR LESS I CERTIFY THATIN THE PERT'ORMANCF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BLCOMFF SUBJECT TU THE WORKERS' COV PCNSATION LAWS OF CALIFORNIA, AND AGREE I HAT IF 151 ICULD 131COMF SUSIECT TOT E WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE,I tHA FORTHWITI I COMPLY%—OVISIONS,, DAT['. _I(/�(.-- APPLICANT. ..._. ._e�-►...”" WAHNING: FAILURE_ TO SECURE WORKERS'COMPFNSAI ION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE IIUNURED II IOUSAND DOLLARS (51 00,000), IN ADDITION 101 HE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDEn PENALTY OF PERJURY THAT THERE IS.A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THL WORK FOR WHICH THIS PERMI I' IS ISSUED (SEC 3097, CIV. C.). LENDER'S NAME LE:NUER'S ADDRESS — _-. _ I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPI Y WITH ALL CITY AND GCUNJY ORDINANCES AND STATE I AWS RELATING TO BUILDING CONS . -L3Y AUTIIOIIIZE REPRESENTATIVES OF TIIIS COON TY FO I Nl i ii UPON 1111.ABOPROPERTY FOR INSPECTION PURPOSES. P' MITTEE NAME (POINT) AA 5 NPLnMITTEE- DATE If I PRESS FIRMLY APPLICATIO �j �� DATE [_.T__ NUMBER p/C ISSUE TYPE OCC DATE_ CONST. GROUP ZONING SETBACKS FRONT RW ------- -- - --- - -- REAR r SIDE/SIDE STREET RW ---------- - --- - ---- SIDE � PROPOSED USEjr !' --- • - —L - t II NO. DWEL. NO. N•-0. UNITS STORIES BEDROOMS _ DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR7_ADD/REM Garage/Carport WPatio/Deck L- Pool/Spa 0 Z —_ _— Re -Root Commercial CIO Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U r U _j DUE 0 Z (n EL Q U Z 2 UJ CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL_ INSPECTION FEE �Ion ISSUANCE ___. _.�✓_.. __ �',{ SMIP— ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: • TOTAL FEES COMMENTS RECPT- NO a PAID BY---�a�-F--�-/ VALIDATION U WHITE-Department Copy, YELLOW -Finance Copy, PINK -Assessor Copy, GOLDENROD -File Copy, GREEN -Applicant's Copy I