HomeMy WebLinkAbout18064 (224) CITY OF DIAMOND B�R +'-.
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DIAMOND BAR i
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
ADDRESS '7-7 2- 'IC i\IA 4 cpi 7R1MN LW
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APN . LOT TRACT Vic)/^ 43
OWNER,p.x). ciiIrr 14 v 4/
ADDRESS .2-' VO itit:Ai 7P-hoic i tv
CITY 11*1-0, ZIP ei ii i fTEL.
APPLICANT .--e-: A i.43.1 TEL.
i 67)I NI itjt„z,Vt.i,r,69 31,
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/ i . o
DESIGNER 'ii) hiAd
tritg=*#
ADDRESS " f I ,471; 111 ../ .,ficit^ +
CITY ( T L -.
A ovoi- ZIP
vl ."7i
.442
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 REOUIRESA PERMIT TO 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 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF 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(8504)1
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).
DI,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 TOW'S OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
0 I 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
9(COMMENCING WITH SECTION 7000)OF DIVISIONS OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS 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 CERTIFICATE 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
I' (11-115 SECTION NEED NOT BECOMPLETED OF THE PERMIT IS FOR ONE HUNDREDDOLLARS($100)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
5 WORKERS'COMPENSATION LAWS OF CALIFORNIA,A AGREE TH IF I SHOULD BECOME
.-. SUBJECT TO THE WORKERS'COMPENSATION Pi:lOV NS OF CT•N 3700 OF THE LABOR.
CODE,I SHALL FORTHWITH COMPLY WIT„ SE !SION
3 '. ,
I DATE: APPLICANT: Vt.
i
I WARNING: FAILURE TO SECURE WORKERS'COMPEN TION COVERAG UNLAWFUL,AND SHALL BE
- SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN'CIVIL FINES UP T E HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF • MPENSATION, D DES AS PROVIDED FOR IN
:( SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
3
CONSTRUCTlON LENDING AGENCY
5
- I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
I- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT*ISSUED(SEC. 3097,CIV.C.).
3
E LENDER'S NAME
z LENDER'S ADDRESS
E I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TI-SE ABOVE INFORMATION IS CORRECT.
L' 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.
3
1
5
° PER 1 'IN
o SIGNI4EOE P R ES DATE
E -
APPLICATION
DATE
IA i olvi PERMIT 1 it NUMBER h #PIC ol 421
ISSUE
DATE
tcp 512.I 161„TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
CI
N0. PROPOSED t STORIES
UNITS i 4'1 I 1 IA,
USE an
I r Mi NIA
DWEL. N0. C,O1
a
N0.
BEDROOMS
DESCRIPTION FACTOR ADJ.AREA/VALUATION
SQ. FT. 6.PSF
SFFt/ADD/REM ,--1.144 ?./5 7._-_--r it:7v 4-... r• i
CI) Garage/Carport
LU Patio/Deck 100
w
u_ Pool/Spa
0 Re Roof
Z
C:1
—J Commercial
5
CO
/_1 i���)�_�
Valuation 45177144 ADJ.AREA
QUANTITY DESCRIPTION FEE
-J ..
'C
,....):
E 1-14 v oulrv.wrratt
I-
LU
-i
a . , s
_lomirmojanammirmic
SIr75:19
os,i0
c..5 ,
Z Ciivie.
CE
-J
i "rti 6
i
I -roiI_icr 4: 1/3'0 Er
2 2 pacr FPg fr-)Olitsl-57e/mis
< 1 ,
2- o...-- ili.
orroto tais-l-�6 A 21.4,Dttel
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE: lilt. '2.,G
i ,II
dna a
0 .
11/
i ....0„ i_
TOTAL FEES 44 E7,^0 511-i
COMMENTS , ,
an 111 Alt CI Y1 f.I _.. I
4111i4ful "'_:0 AA a, 7°,' il f' S, ' 2-----
.,%0/'
RECPT. N0. kill PAID BY VIII ,VALIDATION WO'
ITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,540 WENNUL'—FIIO OI11t1N—
to- keVe-ticol_eocitS3 Fog_.5.0"-cA56,sAALA-5
124-4-OK b3C-4.0 aDy-Kt kab 12reAr(Abbiney3)1/4.39f NYTAcutsi5
/440
W4 9j
t.s0,
Ch.)4,1 14. C-64)