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Home My WebLink About15132 (1092)CITY OF DIAMOND BAR lam/ DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES v 21660 E. Copley Drive Suite 190 (909) 960-3195 Fax (909) 961-3117 BUILDING PERMIT APPLICATION JOBSITE % ADDRESSI��%(� APN LOT TRACT OWNER Ar, /a�ea/-IIS' ADDRESS � 33c cr ='-M J'N I a 4 I 54C111 CITY _1V::a:�11"fi k3r..h ZIP 5244417TEL. k/ti 7.?,r-I APPLICANT TEL. CONTRACTOR ADDRESS /41 A'? i4vr�_ ac • �.. 6 G.^% CITY 1-A0- //I.7 L•. r ZIP 6-V TEL.0-Z j ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HERESY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC 7081.5 BUSNESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WIOCH REOUIRESAPOWITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY 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 LI- CENSE LAW (CHAPTER P (COMMENCING WITH SECTION 70DO) OF DIVISION 5 OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE CI EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7051.6 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TU A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6600).0 O L AS OWNEROF THE PROPERTY, OR MY EMPLOYEES WITH WAGES ASTHEIR SOLE COMPENSATION, WILL DO THE WORT( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". 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 HIMSELFOR HERSELF OR THROUGH IIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR OFFERED FDRSALE IF, HOWEVERTHE BUILDING OR IMPRDVEMENTIS SOLD WTrHINONE YEAROF COMPLE. TION, THE OVMER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O 1, AS OWNER OF THE PROPERTY•AM EXCLUSIVELYCONTRACTNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7041, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U - CENSE LAW DOES NgTAPPLY M AN OWNER OF APROPERTY WHO OU LOS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC- TOUSLICENSE IAW4• D IAM EXEMPT LNDER BEC. B. 6 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 6 (COMMENCING WITH SECTION 7000) OF DIVISION 5 OFTHE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS N FULL FORCE AND EFFECT. �7 y LICENSE CLASS C -16 LIC. NO. DATE L — l c c coNTRAcToR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PENURY ONE OF THE FOLLOWING DECLARATIONS: —I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 970D OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT M ISSUED, I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION 5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORK!l S'1OO�M�PENSATKjU INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER _ ./ T CA4, f. 1111 I POLICY NUMBER 6 b 50 — S (1466 SECRONNEED NOTBE COMPLETW OFTHE PERMIT B FOR ONE "D REDMIAM 010D)OR LESS). I CERTIFY THAT LATHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT LS ISSUED, I SHALL NOT EMPLOY ANY PERSON W ANY MANNER $O 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 8700 OF THE LABOR CODE, i SHALL FORTHNWTH COMPLY WITH THOSE PROM 5ONS. DATE: & ~ gC"00 APPLICANT: PA a /L o / 11- _ ✓ � L 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 DOLLARS (9101 AN). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 57060E THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PENURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. SOW, CIV. C). LENDERS NAME LENDER'S ADDRESS I CERTIFY THAT 1 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. k4,( ti /c IC /Wt /" t I't t PERMITTEE NAME (PRINT) SIGNATURE OF PERMITTEE DATE WHITE --Department Copy, YELLOW—Finance Copy, PINE PRESS FIRMLY C�7 P/C J9� a APPLICATION PERMITNUMBER.,-- DATE ,� � 2,- ^ u i � NUMBER �-� v ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW p REAR ❑ SIDE/SIDE STREET RW ❑ SIDE p PROPOSED USE 47 Ae"'C- t NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR(ADD/REM U) Garage/Carport W Patlo/Deck U- POOVSPa Z Re -Roo! Commercial m Valuation O ADJ.AREA QUANTITY DESCRIPTION FEE J Q U_ U W w a 2 m U_ Z Q S W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL k INSPECTION FEE .b ISSUANCE SMIP 11 R ENERGY P/C Y ' ENERGY PERMIT I�3!=.�• �A = RETENTION FEE: 111 T ,r. f.•7 fi C r. A Y`s � PRE -ALT FEE: TOTAL FEES r OMMENTS l RECPT. NO. PAID BY VALIDATION v%wy, wpy, uneeN—APpllranrs Loopy J