HomeMy WebLinkAbout15138CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY do DEVELOPMENT SERVICES
- , 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE 22 �rr
ADDRESS IJ-1Vo A4 w. -yo;' , -73 1
APN LOT—I)5—
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OWNER — A�G4cf
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ADDRESS 33&0 Amv+t 4 ALot . gt'c /l/
ITY Id 8 -0 - ZIP ?1G4+41 TEL. 9T9 7!s• //33
APPLICANT TEL.
CONTRACTOR ._4n.7
ADDRESS 4A72 4VIC. a,; Js /I2
CITY-T4V.`�.+_ ZIP 720gr 72ITEL. Y%°f9-W'70-170/
ARCWJENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AAI EXEMPT FROM THE CONTRACTORS LI-
CENSE UAW FORTHE FOLLOWING REASON (SEC. 7077.8 BUSINESSAND PROFESSIONS CODE: ANY CITYCR
COUNTVV*M HREQULRESAPERMrTTOODNSTRUCT,ALTERIMPROVE.DEMOUSH,CRREPAIRANYSTRUC-
TUNE, PRIOR TO ITS 16SUANCE. 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 LAW (CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE 49 EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION. ANY VICLATION OF SECTION 7071.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CNLL PENALTY OF NW MORE THAN FIVE HUNDRED DOLLARS (86001.):
O LAS OWNEROF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL 00 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 HOS ORHER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, H OWEVEKTHE BUILDING OR IMPROVEMENT 18 SOLD WITHIN ONE YEAR OFCOMPLE-
TION, THE OWINERHBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR ONE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WTIN LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 701/, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U -
CENSE LAW DOES NOT APPLYTOAN OWNER OFA PROPEF TYYWO BUILDS OR IMPROVES THEREON, AND
WHO
HOCONTRACTSFOR SUCH PROJECTS W:THAOONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE IAW4.
171 AM EXEMPT ANDER SEC. B S 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
e (COMMENCING WITH SECTION TOW) OF DIVISION 7 OF THE BUSINESS AND PROFESSION$ CODE, AND
MY LICENSE L$ N FULL FORCE AND EFFECT.
LICENSE CLASS LIC.
DATE (0 12.0 (7TJ CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 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 WN OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT W ISSUED.
1 HAVE AND WILL MAINTAIN WORKER& COMPENSATION INSURANCE, AS REQUIRED BY SECTION
7700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MYWORKERV OOMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER V AA Afol I'4CA PI TvSJ Af-� ,
POLICY NUMBER h sr 543(,
miS BECKON HE®NOT BE ccwLET®CFTHE Pow S FOR ONE MRNDREDDOLLAAS 0100)0RLESU
I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N 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 PR IONS OF SECTION 7700 OF THE LABOR
CODE. I SHALL FORTIIWITHCGMPLYWIT..SE VISIONS.
DATE: OCl APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE NLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (S100.000), N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 7708OF 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, 7097, CN, C.).
LENDER'S NAME
LENDERSADDRESS
1 CERTIFY THAT I HAVE READ THISAPPLI:ATION 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.
etV
PERMnT AME(PwNn
SIGNATURE OF M
PRESS
FIRMLY
APPLICATION
PERMIT
P/C
DATE—U-20 -20 10
NUMBER
N
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDEISIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL. NOf
UNITS S
B ROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Ch
GaregalCarport
WPallo/Deck
LL
Poovspa
z
Re -Roof
0
Commercial
M
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
VV
OC
Z
J
W
CD
Z
m
U
Z
d
U
W
CONSTRUCTION
PLAN REVIEW
V
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
r
SMIPLla A '1"x
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
t, s 1Nr
AND
i''1mjj,
TOTAL FEES
12 1, 00
O"
COMMENTS
A
0-4
RECPT. NO. PAID BY
n�n '2,XVALIDAnoN
WHITE—Department Copy, YELLOW--FInerNoe Copy, PINK—Assessor Copy, GOLDENROD–.F-119 Copy, O EN—Applicant's Copy
SET BACK FLOOR JOIST
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FTGS'/FORV,S,'S- TELL FHA RL
SLAR GRADE FIREPLACE FOUNDATION
TEMP POW". I'l FIRE.PLACE BOND BEAM
WATER SERVICE I MID 117� BOND BEAM
ROOF SHEATi,,2NiG 8 FT. BOND BEAM
FRAMING,IVENTILIAl ION FINAL BOND BEAM
ROUGH GRADING
ROUGH ELECTF
ROUGH FLUIVIBING FINKSH GRADING
POOL. ELECTRIC
POOL FENCING
0EILING INSULATION OFF SITE IMPS.
N""ILING DEDICATIONS
ON SITE
MIR I EST
FINAL
'FES RAID
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