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Home My WebLink About15122 (650)PIA1100 IIAR CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSIT ADDRESS I I tY O ��g ` V, APN LOT /ACT OWNER F - �A'Y1f 1 —oI 0 ADDRESS r CITY ziPL1QW-n TEII APPLICANT TEL. CONTRACTO '`SO - Ga i ADDRESS CITY la�)f bzM a _ ZIPW 4'J TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U_ CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 SUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOUIRESAPERMITTO 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 SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE UW (CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS OODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP. TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).): ❑ 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 NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH NIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER. THE BUILDING OR IMPROVEMENT IB SOLD WITHIN CNE YEAR OFCOMPLE- TION, THE OWNER-BUIUOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE. DID NOT BUILD OR IMPROVE FORTHE PURPOSE OF SALE). ❑ LAS OWNEROF hIE PROPERTY AM EXCLUSIVELY GONTRACTING'WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U- DENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT 70THE CONTRAC- TORS LICENSE LAW.). ❑ IAM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER B ( ENCINO WITH SECTION 7000) OF DIVISION OF THE BUSINESS AND PROFESSIONS CODE, AND MY UC NSE IS IN FULL FORCE AND EFFECT. "{ I� -74 IN CEN CLASS `-' �+-� ( LIC. NO. M 71`�-� CONTRAC COMPENSATION DECLARATION� I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I1 VEANDWILL MAINTAIN WORKERS'CAMPENSATION INSURANCE, AS REQUIRED BY SECTION 3±. CFTHE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS ED. MY WO RAS' MPEtATION INSURANCE CARRIER AND POLICY NUMBER ARE: C IE R _-�4/.A4J ICY NUMBER SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($100)OR LESS) I ERTIFY THAT IN THE PERFORMANCE OF THE WORKED WHICH THIS PERMIT IS ISSUED. I ALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE OAKERS' COMPENSATION LAWS OF CAUFOR AND AGREE THAT IF I SHOULD BECOME UBJECT TO THE WORKERS' COMPENSA ON ISI NS OF ECTION 3700 OF THE LABOR CODE, i SHALL FORTHWITH COMPLY WITIi 2'PFlOVISI DATE: ' G�� APPLICANT: -. -A_ _ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFLVAND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1 W.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C). LENDER'S NAME LENDER'SADDRESS 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. LrrrJLrv,f_ :'Tr Pffqmrm NAME (PAINT) GNAT R E A7E ;rlPRESS FIRMLY APPLICATION_ ✓. –od PERMIT p5 J 1 1 P/C DATE Y�NUMBER # ISSUE/ �1 ` TYPE OCC DATE �7 CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDE/SIDE STREET RW ❑ SIDE ❑ PROPOSED US)� CA�h e NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD.1REM Garage/Carport WPatio/Deck LL POOVSpa 0 Z Re -Roof Commercial fit Valuation _ ADJ.AREA QUANTITY DESCRIPTION FEE J d U DIE U W LU LU z Z m J a U_ Z d S U LU CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING 1 MECHANICAL ' INSPECTION FEE r.W ISSUANCE �k®r j SMTP ENERGY P/C ae°j✓A ENERGY PERMIT RETENTION FEE: �` faifsz➢ PRE -ALT FEE: v a' TOTAL FEES COMMENTS RECPT. NO. 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