HomeMy WebLinkAboutPR16-580CITY OF DIA,1l`D BAR
DEPARTMENTOF COMMUNITY & DEVELOPMENT SERV `CLz!,
I I I
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
,,, (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building�a7diamondbarca.gov
JOS SITE ADDRESS �k1404 l ' /! S
APN LOT TRACT
OWNER )I 1�5A el C40N
ADDRESS
CITY-fiaem Boyi ZIP TEL.f �f —"APPLICANT r�,. r4 ,r• A&f if , TEL. f 5 - % pL�
CONTRACTO lH
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 Contractor's State License Law for the reasons)
indicated be[ow,0'the checkmark(s), T have placed next to the applicable Items) [Section 7031.5, Business and
Professions Cade: Any`city or,4ounty that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to its issuance, alsgrequires the applicant for the permit to file a signed statement that he or she
is licensed pursuantto the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division 3 of the Business and Professions Code] or that he or she is exempt from licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty,
of not more than five hundred dollars ($500). -
U I, as owner of the property, or my employees with wages hs their sole compensation, will do (_) all of or u portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law doe's not apply to an owner of property who, through employees' or personal effort, builds
or improves the property, provided that the Improvements are not Intended or offered for sale. If however, the building or
improvement is sofa 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.).
U I, as owner of the property, am exclusively 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 contractsforthe projects with a licensed Contractor pursuant tothe Contractors' State
License Law.).
(,) I am exempt from ilcensure under the Contractor's State License law forthe fallowing reason(s):
Date: Sign:
By my signature below I ackrowledge that, except for my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by this permit) cannot legally sell a structure that I have bulli as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the
applicable law. Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or at the following Web sitar http/vvwvv.leginfo.ca.gov/calaw.htrnl.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7090)
of Division 3 ofthe Business and Professions Code, and my license is In full force and effect.
LICENSE CLASS: LIC. NO.: I S D
EXP. DATE: CONTRACTOR:
WORAER'S COMPENSATION DECLARATION
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 Worker's Compensation, as provided by
Section 3700 of the Labor Coda, for the performance of the work for which this permit is issued,
I have and will maintain Worker's Compensation Insurance as required by Section 3700 ofthe Labor Code, for
the performance of the workfor which this permit is issued. My Worker's Compensation Insurance Canter and
Policy Number are: -
CAFIRIERNA11i iPAA ' J i ✓I
POLICY NUMBER C
[THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOP ONE HUNDRED BOLLAPS $1 DO OR LESS).
I will that in to performance of the work for which this permit is issued, I shall not earl any parsec In any manner so as to
became subject to the Worker's Compensation Laws of California. And agree that If I should become suhjecf to the Worker's
Compensall provisions of Section 3700 ofthe Labor Code, I shall forthwith comply with those provislons.
DATE: APPLICANT:
i WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cast of the compensation,
damages as provided for in section 37CS of the labor code, interest, and attorney's tees,
CONSTRUCTION LENDING AGENCY
i 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:
i
I certify that I have read this application and state thatthe above information is correct. I agree to comply with all city and
county ordinances and state Paws relating to Wilding construction, and hereby authorize representatives of this count
t
enter upon the above-mentioned property for inspection purposes.
PERMITTEE NAME T}
SIGNA PERMITTEE DATE
APPLICATION DATE: `.Z 4 P/C# 1
ISSUE DATF: � "7 jib Pi FVZ � ICN —
TYPE CONST. OCC GROUP:
/�
Scope of Work ee -1
I
# OWEL. UNITS # STORIES 9 BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADDIREM
Garage/Carport
cO
W
Patio/Deck
W
LL
Pool/Spa
ZRe
-Roof
Commercial
mife
�� 1<
Valuation.' Adj. Area:
QUANTITY DESCRIPTION FEE
c�
U
J
w
co
m
Q
U_
x
U
CONSTRUCTION:
PLAN REVIEW: 'LCL.
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMI P:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE: e
PRE -ALT FEE:
BASF: I .
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES !
COMMENTS:
P/C: PAID RY: At VALIDATION:
RECEIPT # PAID BY: VALIDATION:
WHITE— Department Copy, YELLOW — Finance Copy, PINK —Assessor Copy
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