HomeMy WebLinkAbout13397 (17)CITY OF DIAMOND BAR
-- DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Saito 190
(909) 960-3195 Fax (909) 561-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS [-O-ZiZ " NOL L
APN LOT 77 TRACT -5A9 41
OWNER
ADDRESS. E-
CITY ZIP TEL. /-
APPLICANT $o! 5 TEL -:,off: /
CONTRACTOR z_S
ADORES / Alf SA�S1
CITY,9!�7m ZIP TEL s'Fo�S
ARCKIENGI r
DESIGNER N
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM LMER PENALTY OF PERJURY THAT I AI EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FORTHE FOLLOW WG REASON ISEC. 7031.8 BUSINESS AND PROFESSIONS CODE: ANYGTYOR
COIMTY WHICH REOUIRESAPFRMITTO CONSTRUCT,ALTER, IMPROVE, DEMOUSH,CR REPAIR ANY STRUC-
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 UW (CHAPTER 9 (COMMENCING WITH SECTION 7808) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CCOE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TON. ANY VIOLATION OF SECTION 7031.8 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACRAL PENALTY OF NOT MORE THAN FIVE ANY
DOLLARS (ISM).):
O LASOWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAOESAS THEIR SOLE COMPENSATION,
WILL W THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, SU%.
NESS AND PROFESSIONS COOS: TIE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHOSUKDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMISELFOR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
EA
. OFFEDFORSALE IF, HOWEVER THE BUILDNOOR UPROVEMENTISSOLDWTHINONEYEAROFCOMPLE-
TON. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF BALE).
O 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. TCU, BUSINESS AND PROFESSIONS COOP: THE CONTRACTORS U.
CENSE LAW DOES NOTAPPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW).
❑ IAM EXEMPT UNDER EEG S. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
*(COMMENCING WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FORCEANDEFFECT. ..
LICENSE CLASS ���� LIC. NO.
DATE 99 CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
- 1 HAVEAW WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF4NSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BYSECiION 37000FTHE LABOR CODE, FORTHE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
__I HAVEAND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERWCOMPENSATION
CA"
RIER AND POLICY NUMBER ARE:
ER
POLICY NUMBER e9/l�,72z
(DISSECTION NEED NOT BECONFLEIEDCFTIE PERMIT IS RTRONE W OREDDCUARS MOD) OR LESSL
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT M 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 37x0 OF THE LABOR
COOE.1 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 CML FINE$ UP TO ONE HUNDRED THOUSAND
DOLLARS (8100,000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR N
SECTION 3700 OF THE LABOR CODE. MEREST. 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. 3097, CIV. C.I.
LENDER'SNAME ®UIr
LENDER'S ADORES$
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TNEABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY MTN ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COLNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
EVAJA4d TSR RAMI D1/�
PERM,RVE NAME IPRINi)
G TU E OF PERMITTEE DATE
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PRESS
FIRMLY
APPLICATION PERMIT PERMIT P
�
DATE ')5�/9% NUMBERI3 « r
ISSUETYPE OCC
C
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
C/3
Garage/Carport
WPallaMaCk
LL
POOVSpS
ZRe
-Roof
C1
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
POOL f: L c NQtG
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W
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4 -12 'S'T - �
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CONSTRUCTION -
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL _
INSPECTION FEE
ISSUANCE Im 00
SMTP A i . D
ENERGY P/C ) ?Tz, _
ENERGY PERMIT IYL� ` - -• ], 7
RETENTION FEE:, - t N �•
PRE -A F
TOTAL ES
COMMENTS
A 40
RECPT. NO. PAID BYVALIDATION
WHITE—Department Copy, YELLOW—Finsnos Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy
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