HomeMy WebLinkAbout14070 CtTY OF DIAMOND BAB � � ^J rj �
-- DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES U�"
� , 21660 E.Copley Drive Suiu 190 �,
(909)860-3195 Faz(909)861-3117 PRESS
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� STATEMENT THAT H6 OR SHE IS 4CENSEO PUfi5UAN7 70 THE P%OVISIONS OF THE CONTRACTORS LI-
� CENSE LAW(CHAP7ER e(WMMENGINa WITH SECTION 7000)OF UIVISION 3 OP THE BU51NE55 AND PRO- � PoOVSpa
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WILL DO THE WORK,AND THE STAUCTURE IS N071MENDED pA pFFERED FOR SALE(SEC 7oa4,BU51- �
� l�SS M1D PiiOFESSIONS CODE.TNE CONTRACTORS LICENSE LAW OOES NOT APPLY 70 AN OWNER OF j
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� LICENSED CONTRACTURS DECLARATION W
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[� 9(COMMENqNOWITMSECTION70o0)OFDIVISION30FTHEBUSINESSAN�PROFES510NSCA�E,pND z 1/� �
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p OFTHE WORK FOH WHICH THIS PERMIT IS ISSUED �
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Q37000F7NELABORCODE,FORTHEPERFORMANCEQFTHEWORKFORWHICHTHISPERMITIS t� I"R/q 1^0
� ISSUED.MY WORKEflS'GOMPENSATpN INSUR�ANCE Cq�,q/RIEq AND POLICV NUMBERARE CONSTRUCTION w � 1 L�h. "/
� cnaa�ea Gi��� �(iY�+-�I PLAN REVIEW `��� �"�-��
� aa.�cr nun�en ��o� ELECTRIC ni ...
a
Q �Q (Ih763ECTptJNE�NO7BEQJAIRETIDOFTFEPEFANTI3FORONEFRX�DREDDOLIMS(SI00)ORLESS' PLUMBING �
Z I CEHTIFY THAT INTHE PERFORMANCE OF TME YJORN FOR WHICH THIS PEflM1T IS ISSUED,I MECHANICAL �
C� SHALINOTEMPIOYANVPER50NINANVMANNERSOASTOBECOMESUBJECTTq7HE � .
(ry WOflKERS'COMPENSATIONI,qW30FCALIFOANIAANOAGREETHATIFISHOULDBECOME INSPECTIONFEE
S SUBJEC7TOTHEWORKERS'COMPENSATIONPROYISIpN50FSECT10N37000FTHElA80R
CODE,1 SHALL W ITH COMPLY WlTH THOS�RDy1S S�� �SSUANCE �
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p DATE• �'�M � APPLICANT. SMIP �
J WARNING FAILUfiE TO SECU E WORKEHS'COMPENSATION CC]VEHAGE IS UNUWFl1L,ANb SHALL BE ENERGY P/C _
� SU&IECTANEMPLOYERTOC IMINALPENALTtESANOCIVILFINESUPTOONEHUNOREDTHOUSANO ENEFGYPERMIT
DOLURS(S7a0,o00).IN ADDI710N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION37aBOFTHELABORCODE.INTEREST.ANDATTORNEY'SFEES RETENTIONFEE" � _ �
OCONSTAUCTION LENDING AGENCY PRE-ALT E: �� ' �
� I HEHEBY AFRHM ONOER PENALTP OF PERJURY THAT THERE IS ACANSTRl1CTION LENDING AGENCY
FOR TNE PERFORMANCE OF 7HE WORK FOR WH1CH THIS PERMIT IS IS5UED(SEC 3091,GV C). �
W
� LENDER'S NAME
F— LENDER'SRDORE55
� TOTAL FEES '
� ICERTIFYTHATIHAVEREPDTMISqPP�IcqnVNANDSTATETHATTHEFeoVEINFORMATIONISCOpRECT.
� IAGREE TO CAMPLV WITH ALL CIlY AN�CAUNTY ORDINANCE5 AND STATE LAWS flELATMG TO BUILDING
� CONS7qUCT10N,AN�HEFEBY AUTHORIZE REPRESENTAT1VE30F iHIS CWNTV TO ENTEq UPON THE
Z ABOYE-MF,NrIONEDPflOPER7YFORINSPECTIONPUHPO5E5. COMMENTS
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� � RECPT.NO. PAID BY VALIDATION
WHITE—Department Copy,YELLOW--Finance Copy,PINK—Assessor CoDX GOLDENROD--File Copy,GqEEN—Applicant's Copy
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DIAMOND BAR{1
PRESS FIRMLY
CITY or DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JBSITE
%s 2-)-g (A)eftin-C491A14-e'
APN LOT TRACT
. i
OWNER /vl,l. • et.."•-••
ADDRESS Z CS% 040,C..9-kh a -
CITYDA ta.. ;An-ZIP 41-1- TEL.
APPLICANT TEL.
CONTRACTOR r• , .... 4, 4 .4 .4 ^
„A
ADDRESS _ . ' re,0... /
CITY - .41111M ZIP C4 TEL'DEW ,s,
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
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 BUSINESSAND PROFESSIONS CODE-ANY CITY O11
COUNP(WHICH FIEQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STFIUC-
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(CHAPTERS(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($000))
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 TO AN OWNER OF A PROPERTY WHO BUILDS OR 9.4PROVES 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.0 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 DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS C') LIC NO 4/5 P-I
DATE /""-t V".-/ CONTRACTOR fe)(441
_(lufac.. .
WORKERS'COMPENSATION DECLARATION \,-9-�).-t
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAT/ONt,
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 370007 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 6 4,9
POLICY NUMBER /'4 . 7 De
(Irossr-cnoNNEECAOTBECOMFLETIEDOFTHEPERMIM FOR ONE HUhDREDDOUARS($103)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 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,/SHALL RI ITH COMPLY WITH THOSE PROVIS S
1 .
DATE- 14 4 c
It APPLICANT.
WARNING FAILURE TO SECU E WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(9100000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
CONSTRUCTION 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 INSPECT/ON PURPOSES.
r AIA c. e-H a•-nJ•
PERMI TTEE . 1 .. — (0'
4111".417./IPP ..c. _...1 /
SIGNATURE OF PER ' E...0.- .411P- ..-
EATS
APPLICATION
DATE
..,,I 9 pNE,FtwAmEITFI 016#PgCt-50.
....)0
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
0
40POSED
N0.
UNITS
USE
DWEL. pATI 0 (0 v-6--rz-.
N0. N0.
STORIES BEDROOMS
(.0
1-1-1
LIJ DESCRIPTION
11-
0
z SQ. FT FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck Or)(2,2) &)-. '14 -
PooVSpa
Re-Roof
a
) Commercial
5
CO
115-13
>Valuation
ADJ.AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE'
PRE-ALTIE: I A 12-6,--0
b 2... 1.4 3
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2 416
y-tcr
TOTAL h-
COMMENTS FEES 211 b 0
RECPT. N0. PAID BY VALIDATION \TC.)
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
CITY OF AMD NSPECTiON ECORD
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