HomeMy WebLinkAboutPR15-1449Di r ONTl D
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION
JOB SITE ADDRESS
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OWNER
ADDRESS
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CITY r ZIP TEL. ori
APPLICANT /' TEL. .�
CONTRACTOR
ADDRESS 7 2
GITYZcs�Cy ZIP EL.�J'�I ^i 1 �� l
ARCH/ENG/DESIGNER_
ADDRESS
CITY A ZIP EL
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reason(s)
indicated below by the checkmark(s), I have placed next to the applicable items) (Section 7031.5, Business and
Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicant for the permitto file a signed statement that he or she
is licensed pursuantta the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division 3 ofthe Business and Professions Code] orthat he or she Is exempt from licensure and the basis for
the alleged exemption. 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 (5500).
U 1, as owner of the property, or my employees with wages as their sole compensation, will do U all of or (.) portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Coda, The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds
or Improves the property, provided thatthe improvements are not Intended or offered for sale. If however, the building or
Improvement Is sold within one year of completion, the Owner -Builder will have the burden of proving that it was not built
or improved for the purpose of sale.),
(..) i, as owner of the property, am exciuslvely contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors State License Law does not apply to an owner of property who
builds or improves thereon, and who contracts forthe projects with a licensed Contractor pursuant tolhe Contractors' State
License Law},
U I am exemptfrom Ilcensure under the Contractor's State License law forthe following reason(s):
By my signature below I acknowledge that, excepttor my personal residence in which I must have resided for at least one
year prior to complelion of the improvements covered by this permit,] cannot legally self a structure that i have built as an
owner builder if it has not been constructed in Its entirety by licensed contractors. I understand that a copy ofthe applicable
law, Section 7044 of the Business and Professions Code is available upon requestwhen this application is submitted or of
thefahowi gWebsite.http/www.leginfooa.govfcafawhtml.
GATE SIGN:
LICENSED CONTRAC1WS DECLARATION
I erehy 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 CLAS - C 16 LIC. NO.:
DATE: I I i A ho 171 CONTRACTOR:
WORKER'S GODECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATICNS:
have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
i have and will maintain Worker's Compensation Insi. as required by Secfion 3700 of the Labor Code, for
the performance cfthe work for which this permit Is issued, My Worker's Compensation Insurance Carrier and
Policy Numberare:: �4 —
CARRIER . -
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLIFFTHE PERMIT IS FOR ONE HUNDRED DOLLARS ($100) OR LESS),
I certifythat in the performance cf the work for which this perrnit is issued, I shall notemploy any person in any manner so as to
become subject to the Workers Compensation Laws of Califarl Andthat tf I should become subject to the Worker's
Compo 7/aiFure',to"s�ccure
°°� cbar 3700 of the Lab de, l -i I o 6withtomply with those provisions.
"'TE:�p�APPLICAN7: �WARNIN Worker's Compensation covorag Is upl ui, and shall subject an employer to criminal
punall and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the 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, Cv. 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,ord'mances and state laws relating to building construction, and hereby authorize representatives ofthis county to
enter upon the above-mentioned property for inspection purposes
P Mim IE(PAINTI
SIGNATURE OFPERMFTEE DATE
PRESS
FIRMLY
APPLICATION DATE: P/ #
ISSUE DATE: 1� PERMIT#
TYPE CONST. OGC GROUP:
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USS,. -,,1 bUt If
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# DWEL. UNITS.._I # S DRIES #BEDROOMS_
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
SFPJADD/REM
Garage/Carport
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Patio/Deck
LL
Pool/Spa
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Re -Roof
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Commercial
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Valuatio _Adj. Area:
QUANTITY DESCRIPTION FEE
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CONSTRUCTION: I
PLAN REVIEW:.
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP: A.,
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE: _ r
PRE ALT FEE:
i
TOTAL FEES
COMMENTS:
RECEIPT#.� t-�M PAID 6Y: �� _ _. VALIDATION: ....__
WHITE —Department Copy, YELLOW — Finance Copy, PINK— Assessor Copy, GOLDENROD —File Copy, GREEN Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION