HomeMy WebLinkAbout14928 (1090)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3193 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
ADDRESS— f,:7— 7 �-/ �
APN LOT TRACT
OWNER
ADDRESS O
CITY TEL.
APPLICANT TEL
I CONTRACTOR
ADDRESS &1
CITY ZIP TEL.
ARCWEN /
1 DESIGNER
ADDRESS
i CITY ZIP TEL.
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS U•
C M,E LAW FORTHE RXLONIINO REASON (SEC. 7031.5 SUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESA PERMrTTO CONSTRUCT,ALTER a1PROVE. DEMOUSH,CR REPAIRANY STRUC-
I TUBE, 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 U.
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 70001 OF DIVISION S 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 7691.E BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (46004):
D LAS OWNER OFTHE 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 A1ND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERrYW Ho BULD9 OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTSARE NOT MENDED OR
OFFERED FOR SALE. F, WMEVER TIE BUILDING OR IMPROVEMENT U SCLO WITHIN ONE YEAROF COMPLE-
YXK THE OWNER -BUILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U-
�_ CENSE LAW DOES NOTAPPLYTOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
W6gCONTRACTSFOR SUCH PROJECTSNITH AOCNTRACTOR(S) LICENSED PURSUANTTOTHE CONRUb
TORS LICENSE LAW.)L
O 1 AM EXEMPT LNDER BEC. B. A P.C. FOR THIS REASON
DATE OWNER
[_5 LICENSED CONTRACTORS DECLARATION
C I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
L F (CAMNAENCWG WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
5 MY LICENSE IS N FULL FORCE AND EFFECT
LICENSE CLASS �^ ✓ r LIC. NO.
DATE X — .;;jO�'r� CONTRACTOIR
WORKERS' COMPENSATION DECLARATION
n I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
n
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION $700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT U ISSUED.
ll I HAVE AND WILL MAINTAIN WORKERS- COMPENSATION INSURANCE, AS REWIRED BY SECTION
? 9700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORK? P SAT NSU CARRIER AN ICY NUMBERARE:
CARRIER -
POLICY NUMBER
(Im SEC. NEED NOT BEC MIN-FEDOFT E FEW S RORC6E HUNDRED DOl1NG1T10D)0RLESSI
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECAME SUBJECT TO THE
n
WORKERS COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO ORIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ISI 00,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
JJLA SECTION 5705 OF THE LABOR CODE. INTEREST, AND ATTORNEYS 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 (SEG 5057, CIV C.).
Z
LENDERS NAME
LENDERSADDRESS
I CERTIFYTHAT 1 HAVE READ THIS APPLICATIONAND STATE THATTHE ABOVE INFORMATION 13 CORRECT.
AGREE TO COMPLY WITH ALL CIM 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.
s
PERMITTEE NAME P `
Co SIONATURE CfPE E DATE L
PRESS
FIRMLY
APPLICATION
PERMIT
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DATE _
NUMBER
R
ISSUE
TYPE
OCC
DATE '/1�, GAB ri
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
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REAR
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL. NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/AOD/REM
Garage/Carport
W
Patlo/Deck
LL
POOVSpa
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Commercial
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Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
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ENERGY PIC
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ENERGY PERMIT
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENTS
RECPT. NO. PAID B
VALIDATION
WHITE—DepeRmenl Copy, YELLOW—FYfanee Copy, PINK—Assessor QW. GOLDENROD --Elle VOPy, GHEtN—APVICanFS GqW