HomeMy WebLinkAbout10870r
0
O
LL
0
w
z
O
0
m
CC
O
0
w
0
z
w
U)
cn
U)
cn
U)
O
C)
W
C.i
z
w
O
Ci
O
z
W
W
C)
z
LU
W
H
O
LI_
¢i
W
d
W
0
U
W
U)
U)
rn
0
z
Q
Lu
W
Q
J
0
z
Q
W
Z
0
O
0
W
J
J
fT
Ir
W
O
W
z
W
H
LU
W
a
C.7
0
J
Q
S
CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE //j� r- ®i' .Z—
ADDRESq/A2—.?,,ice `Ui9tP �iVG.+� 39 �!_
APN LOT TRACT 0 C %
OWNER 2-6 =
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
N,CONTRACTOR .SAl
A RESS tv `j0 "1.' j/ky
CITY GIB i rJ a ZIP 9 dl t 0 TEL,_ ,M 6550
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 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANYSTRUC-
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 FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (E500).):
❑ 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, BUST.
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 OFCOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ I, 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 NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
❑ I AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
M HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 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. r
iCENSE CLASS � ' ® .NO.
TE CONTRACm D9f,
WORKERS'COMPENSATION DEC RATION
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 37GO 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 NEEDNOT BE COMPLETED OFTIE PERMIT IS FORONE HUNDRED OOLLARS ($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 BOAS 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, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000), IN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 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
M 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.
op P EE NAME (PRINT) �
SIGNAT RE OFPE M EE DATE
APPLICATION /A-1 NERMIT UMBER 1040 #/C
DATE /
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE 0—
PRO OSED USE '� NG� ���T�ti
NO. DWEL. NO. NO.
UNITS STORIES "BEDROOMS
DESCRIPTION
SQ. FT
FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
W
Garage/Carport
W
Patio/Deck
LL
Pool/Spa
ZRe
-Roof
Commercial
5
-
Valuation ADJ.AREA
QUANTITY
DESCRIPTION
FEE
a
3�
'�oar�s �r F'i• it
Zyy• s=a
w
rJG'/V .SSG G /OG
J
w
/-7
/Li05
33�• rG
CONSTRUCTION
LAN REVI
PLUMBING
MECHANICAL
INSPECTION FEE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
�: 8 • l�� � r-�-,L9-yam
RECPT. NO. PAID BY VALIDATION
WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy