HomeMy WebLinkAbout17396 (668) CITY OF DIAMOND BAR �'
---�`� -- DEPARTMENT OF COMMUNI'I'Y&DEVELOPMENT SERVICES �
I 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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� C7 SHA�L NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
Uj WORKEHS'COMPENSATIONLAW30FCALIFOqNIA,ANDAGRE�THATIFIS qULDBECOME INSPECTIONFEE
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� SUBJECTAN EMPLOYEF TO CRIMINAL PENALTIES AND CIVIL FMES UP TO ONE HUNDRE�THOUSAND ENERGY PERMIT �
� DOLLAFiS(E10o,o00),IN AODITION TO THE GOSTOF COMPENSATION.DAMAGES AS PROVI�E�FOfl IN
SECTION37000FTHELAeOFCODE.MTEFEST,ANDATTORNEY'SFEES. RETENTIONFEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ' -
� I HEREBY AFFIRHI UNOER PENALTY OF PERJURY THAT THERE IS A CONSTFUCTION LENOING AGENCY
FOR THE PERFOAMANCE OF THE WOR7(FOR WHICH THIS PERMIT IS ISSUED(SEC,3097,CIV.C.).
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� LEN�ER'SNAME — �
1— LEN�ER'SRDOflE55
� TOTAL FEES /
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. (�
W 1 AGREE TO COMPLY WITH ALL CITV AND COUNTY OFDINANCESAND STATE LAWS RELATING 70 BUI�DING (� i-��r�
� GONSTFUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
zABOVE-MENTIONE�PFOPERTY FOR INSPECTION PIJqPO5E5.
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� SIGNATURE OF PERMITTE - DATE •
� RECPT.n�0. PAID BY VALIDATION
WHITE—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
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1
PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE (.9 3 .,...,,,2.2_, .
ADDRESS 'Z(../it.
APNLOT TACT
OWNS-7-i 72-4-1.7 c., .4---/I-
ADDRESS 23' e e,--.-og,— Ada
a,
CITY p s a IP TEL. eS2C/-5*-3"Z
/
APPLICANT 42„a1.4o.,i9/
i.
CONTRACTOR 0
ADDRESS 9,..-<
CITY ZIP TEL.
ARCH/ENG/, .1,,t p
DESIGNER^JA/4"i....&IV',/k.) DO-1.r3E-4-
ADDR4SS e
CITY', ^ 5 ".> . ZIP '
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO 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 LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION SOP THE BUSINESS AND PRO-
FESSIONS CODE)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 CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
0 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 HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE,IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O1,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW,).
CD I AM EXEMPT UNDER SEC. AO/YAP BA,C. FOR T E.. N
AI^ :411',/ if
DATE VAIVILgr OWNEIaiI an=rikilM.
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISIONS OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSES IN FULL FORCE AND EFFECT
LICENSE CLASS LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERT/FICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE 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'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS(S1 00)OR LESS).
I 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'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I S LD BECOME
SUBJECT TO THE WORKERS'COMPENSATION P'ISION CTIO • 'SOP THE LAB°.
DE,I SHAVRTHWITH COMPLY WITH T,,-7. RO-ON
DATE:47---0 -.bet'
APPLICANT: ...,,,,,.// '
/
WARNING: FAILURE TO SECURE WORKERS'COMPENSA ION COVERAGE IS UNLAWFUL,AND S LL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC,3097,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
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.
PgITTEEILAM9IRINT)
--V
SIGNATURE OF PERMITTE 8/ ... DATE
WHITE—Department Copy,YELLOW—Finance Copy, PIN
IIPPLICATI144
DATE
0
,I a, PERMIT,...,:51L P/C 0 1., 37
NUMBER I I kii #
ISSUE
DATE
IN 0 TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
D
SIDE/SIDE STREET RW EI
0
PROPOSED
N0.
UNITS
USE
DWEL. 1 L. 4 ie,,,1 (0(P-6
L.....0357,-mipmnimPastrairzwf-_,.. .a
2prar"-e4PALM MUI PETP
0 N0,
STORIES BEDROOMS
CD
U-I
w DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
I.E.
0
Z
SFR/ADD/REM
Garage/Carport
Patio/Deck
PooVSpa
Re-Roof
E
J Commercial
5
co
06
Valuation 1-4-170. ADJ.AREA
QUANTITY ASCRIPTION FEE
J
<
C.)
E
i--
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w
-.I
DJ
a
z
E
2
i
a
1
<
0
2
<
0
Lu
2
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE: 14"79.10
-lei-- Z.
OQ
4t48
14—
I
1111111111M12
s
I
TOTAL FEES 52_3,10
COMMENTS
NK7,.-77D1-1
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CcARECID"—T,
1.--() VALIDATION