HomeMy WebLinkAbout14990 (664)g CITY OF DIAMOND BAR
lM DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
ADDRIESS 22734Y �I �`1 UC/CI / lli L j /jivC
APN LOT TRACT
OWNER C-, r IES. DOZ 1/4 -
ADDRESS BEP-
CITY U, I G TEL.
APPLICANT
CONTRACTOR
ADDRESS CLQ N IVC tR- /
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DESIGNER p1cl LetAal
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CITY 101111 E�If ZIPTELT]/ 3lTCJZ�
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4
CENSE UW FOR THE FOLLOWING REASCN (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANYCITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER IMPROVE. DEMOUSH, OR REPNRANY STRUC-
TURE. PRIOR TO 175 ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L4
CENSE LAW (CHAPTER S (IXOMMENCNG WITH SECTION 7000) OF DIVISION a OF THE SUS'NESS AND PRO.
FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION. ANY VIOLATION OF SECTION 707I.S BY ANYAPPLICA W FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOTMORE THAN FIVE HUNDRED DOLLARS D500) I
CIL AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTYWWHO BUILDS OR IMPROVES THEREON. ANDYWIO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR $ALE IF. HOWEVER THE BUILDING OR IMPROVEMENT ISSOLD WRHN ONEYEAROF CCIMPLE.
TION. THE OWNER4WILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS COCE: THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY TON/ OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
VAHO NT
CONTRACTS FOR SUCH PROJECTS WITH A CORACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE LAW).
EO I AM EXEMPT LINDER SEG B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIM LNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
S (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
W LICENSE IS N FULL FORCE AND EFFECT. p
LICENSE SS C- ~ J LIC. NO. D *>- y0 Nfn
DATE x%17 CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM LNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECIMATIONS.
I HAVE AND WILL MAINTAIN A CEFTTIrICATE OF CONSENT TO SELFMNSURF FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 67000F THE LABOR CODE, FOR THE PERFORMANCE
CF THE WORK FOR WHK>i THIS PERMIT 15 ISSUED.
I HAVE AND WILL MANTAN WORKERS' OOMPENSATION INSURANCE. AS REQUIRED BY SECTION
.700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' C PEN ATION JJWSURMCE C(A/yi :ER AND POLICY NUMBER ARE:
CARRIER _� T—�^"",-f
POLICYNUMBER �/ 4 O 3 S-7 NI; — o
(TEAS SECTION NEED NOTBE a3PL£TEDOFTIE PCMM7IS FCnCINE HU DiEDDDLLARS (zero) CRLESS}
1 CERTIFY THAT N THE PERFORMANCE Or 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/I SHALL FORTHWI COMPLY WITH THOSE PROVIS
DATE. J„� PLICANT
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOHA e(III o0,000), N ADDITION TO THE COSTOF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 370e OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFRRM LNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 0097, CIV C.).
LENDERS NAME
LENDERSADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE NFORMAT*N IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDNANCES AHD STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRCSENTATNES OF THIS COUNTY TO ENTER UPON THE
ABOVEaME ED PROPERTY FOR INSPECTION PURPOSES,
PER EE NAM P
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SIGMA PER DATE
PRESS
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APPLIC N ^ PERMIT . P/C (^
DATE `/ NUMBER D i VK: `�
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR O
SIDEISIDE STREET RW p
SIDE 0 -
PROPOSED USE
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NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADDIREM
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WPatio/Dock
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0
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Valuation 0-% ADJ.AREA
QUANTITY DESCRIPTION FEE
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COMMENTS
RECPT NO. PAID BY VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy