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Home My WebLink About14960 (655)— -1\ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES W 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION —_ JOBSITE ADDRESS APN LOT TRACT, OWNER ADDRESS CITY ZIP / BTEL. APPLICANT TEL. CONTRACTO ° "ice ADDRE 5 CITY f 211 % % WEL. �;• ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH,OR REPAIR ANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SIZE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER S (COMMENCING WITH SECTION 7W0) OF DIVISION 3 OFTHE BUSINESS AND PRO- FESSIONS ODDE) OR THAT HE OR SHE I$ EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIO ATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).): ❑ I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS 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 NOTAPPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORKHIMSELF OR HERSELF OR THROUGH HS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORSALE.IF, HOWEVERTHE BUILDING OR IMPROVEMENT IS SOLO WITHIN ONE YEAR OFCOMPLE- TIN1, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ❑ I. AS OWNER OF THE PROPERTY, AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WH) CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG NRS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER B (COMMENCING WITH SECTION TWO) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND MY LK:ENSE LS IN FULL F CE D EFFECT. LICENSE CLASS s" UC. NO. . DATE CONTRACTOR �ION WORKERS'COMPENSATION DECL 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATKNIS: _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SGUF-INSURE FOR WORQ' COMPENSATION. AS PROVIDED BY SECTION 3700 OF T HE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I 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' COMP�N$ATHNI INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER �//9`'�R//J6) - - POLICY NUMBER��. (MIS SECTION NEEDNOTBE COMPLETED OF7HE PERMIT IS FOR ONE H NDREDDOLLARS (5100) ORLESS). 1 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'COMPENSATKON LAWS OF CAU FORNIA, AN D AGREE THAT I F I S BECOME SUBJECTTO THE WORKERS' COMPENSATION PROVI% OF SECTION 3700 O E LABOR CODE, SHA L{jByIjTH COMPLY WITH THOSE RO $�� J✓} �•j%}APPLICANT: DATE: / WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (51 00,000), IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HERESYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED MGC. 30W, CIV. C.). LENDER'S NAME LENDER'S ADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CIT' AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING STRUCi[ON. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE E -M NTKONED PROPERTY FOR INSRS M�PtOZ . 'PERM1 `, ,E NAME (P, SIGNA EOF PERMITTE DAT PRESS FIRMLY APPLICATIC, PERMIT � P/C DATE DATE .•...•..JJ NUMBER # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garaga/Carport WPatio/Deck LL Pool/Spa Cq Z Re -Roof Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U H U w LU CD ZEE CL Q U_ Z Q w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING ��✓ MECHANICAL INSPECTION FEE q ISSUANCE y SMIP p Kip -•,el r'45"l ENERGY P/C T Cly'' ti o i >L ENERGY PERMIT 1-1,CI 3 RETENTION FEE: PRE -ALT FEE: TOTAL FEES G% G/ COMMENTS RECPT NO. - PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finan Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy - ."* ", %3-: ` W"I" ir" - 'f,' f"O toy&, t—hw WTQ Not A