HomeMy WebLinkAboutPR16-1541CITY OF DIAD ,,D BAR
DEPARTMENTuF COMMUNITY & DEVELOPMENT SERVICLe,
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (969) 839-7027 FIRMLY
BUILDING- PERMIT APPLICATION www.cityofdiamondbar.com buildiug@diamondbarea.gov
JOB SITE ADDRESS
APN LOT TRACT
OWNER 11° e_ 0-pA
ADDRESS �J - r.L
CITY ZIP TE .
APPLICANT TEL.
CONTRACTOR Vill 4C21✓L % C
ADDRESS �f0 0 h / 1 *A `3
CITY l ZIP a Q TEL. « D
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affimn 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, after, improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she
is licensed pursuant to 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 11censure and the basis for
the alleged exemption. Any violation of Sactien 7031.5 by any applicant far a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
(J I, as owner ofthe property, or my employees with wages as their sole compensation, will do U all of or I-) portions
of the work, and the structure is not intended or offered for sale (Section 7944, Business and Professions Cade: The
Contractors' Shote License Law does not apply to an owner of property who, through emp€oyees' 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 sold within one year of compleffon, the Owner -Builder will have the burden of proving that it was not ballt
or improved tar the purpose of sale.).
(-)1, as owner ofthe property, am exclusively contracting with licensed Contractors to construct the project (Section
7944, Business and Professions Code: The Contractors' State L€cense Law does not apply to an owner of properly who
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuartto the Contractors' State
License Law.).
I-) I am exemptfrom licensure underthe Contractor's State License lax forthe following reason(s):
Date: Sign:
By my signature below, I acknowledge that, except far my personal residence in which I must have resided for at least one
year prior to completion of the Improvements covered by this permlt,l cannot legally sell 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 of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or atthe following Web site: http/www.leginfo.ca.govlca€aw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
�Ifoff. Division 3 of the Business and Professions Code, and my license is infullforce and effect,
ENSE
LIC
�FXCP. DATE:_ 5t l�7 CONTIRACTOR: �eB rl i��.4 S 4yzx- /d YJ'�
�'Or WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY or PERJURY ONE OF THE FOLLOWING DECLARATICNSr
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensatlon, as provided by
Section 3700 ofthe Labor Code, forthe performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance ofthe workfor which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are-
CARRIER
AA
CARRIER �e 5 CPQ till V1rA ✓f C L ® a ✓1
ly
POLICY NUMBER e
(THIS SECTION NEED NOTBE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certifythat in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so a; to
become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to the Worker's
Compensation provisions of Section 3700 ofthe tabor Code, I shall forthwith comply with those provisions,
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shalt subject an employer to criminal
penalties and civil lines up to one hundred thousand dollars ($100,000), in addihon to the cast of the compensation,
damages as provided for In section 3700 of Are labor code, interest, and atlomey'sfees.
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:
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 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.
✓&^ PA y Il J
ERMFI NAME (P ® d
GNATU ERMITTEE DATE
APPLICATION DATE: B` 1, f l Ln, P/C# 1FQ '1,6.-
ISSUE DATE: 1 PERMIT# : �6 e k 1
TYPE CONST. OCC GROUP: _
Scope of Work Rv=
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF ADJ. AREANALUATION
SFHIADDlREM
Garage/Carport
LW
L
Patio/Deck
LU
LL
Pool/Spa
ZRe
-Roof
0_
Commercial
Valuation:
6eviv 6P3 Adj. Area:
QUANTITY
DESCRIPTION FEE
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CONSTRUCTION:
PLAN REVIEW
ELECTRIC:- 1
0,
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:___
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: PAID BY: VALIDATION:
RECEIPT # - C. PAID BY: ' VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK —Assessor Copy
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