HomeMy WebLinkAbout14926 (1088)CITY OF DIAMOND BAR
- DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)961-3117
y B[JIIAING PERMIT APPLICATION
JOBS
AD RIESS O f_
APN LOT T CT
OWNER
ADDRESS
CITY ZrTEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
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. 7031.6 BUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WIBCH REOUIRESAPERLDTTO CONSTRUCT, ALTER. IMPROVE. DrMOUSH,OR REPAIR ANY BTRUC-
TURE, PRIOR TO ITS ISSUANCE, ALSO REWIRES 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 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSODOE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASISFOR THE ALLEGED EXEMP-
TION . ANY VIOLATION OF SECTION 7081.6 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
M
A CL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5600).):
0 LAS 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 ISEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY MIO GUILDS 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 W, HOWEVER, THE BUILDING OR IMPROVEM ENT O SOLD WITHIN ONE YEAR OFOOMPLE-
TION, THE OWNER -WILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF BALE).
O L ASOWINEROFTHE PROPERTY AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (BEC. 70". BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND
VA4000NTRACTS FOR SUCH PROJECTS WITHIACONTRACTOR(S) LICENSED PURSUANT TO THE OONTRAC-
TORS LICENSE LAW).
O 1 AM EXEMPT UNDER SEO S. 6 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
B (OOIMMENCNO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE 15 IN FULL FORC D EFFECT.
LICENSE CLASS _� LIC. NO.
DATE � �,� C2A CONTRACTOR
4
WORKERS' COMPENSATION DECLA ION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
IH HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR ADE, FOR THE PERFORMANCE
OF THE WORK POR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37W OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHI IS PERMIT IS
ISSUED. MY WORKERT'�NBURANCE C/g.JFi1 Al POLICY ER ARE:
CARRIER TTJ
POLICY NUMBER ! C_
(IMSECTIONNEEDNOTBEOOLPLETEOOFTIEPERMTBROAONEH.IDFRMDML Ft8IS100jORLUSS)
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 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE WORKERS' DOMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (S 100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 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. 3W7, CIV. C.),
LENDERS NAME
LENDERSADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY MID COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TD ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (P _
SIGNATURE OF PERM _ neTE
OfPRESS
FIRMLY
APPLK:ATION •
PERMIT
P/C
DATE
NUMBER
8
ISSUE
DATE S _y:_27100 v
TYPE
_
OCC
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL. NO.,'
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREAlVALUATION
SFR/ADOIREM
Gara®erCarpolt
Path0eck
LLLI
IL
POGVSpa
Re -Roof O
0
Commercial
5
Ib
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
U
S
U
W
W
2
C13
U
z
2
U
w
(2T7
CONSTRUCTION
V'V
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SHIP
0
8 2600
ENERGY P/C MAY
ENERGY PERMIT C�MOND
BART
RETENTION FEE:
1
PRE -ALT FEE:
TOTAL FEES
%.
70
COMMENTS
RECPT. NO PAID BY
VALIDATION
wnn c --v 0 mens Uopy, YhLLow—+-mar= Capt', PINK --Assessor Copy, GOLDENROD—File Copy. GREEN--Wicant's Copy