HomeMy WebLinkAboutPR17-0630"M BAR
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
i BUILDING PERMIT APPLICATION www.cityofdiamondbarcom building@diamondbarea.gov
JOB SITE ADDRESS f 0 [.l � * l `5—
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP jTTEL, 'S iO 720—vqbll
APPLICANT TEL. �_ firms "Sn
CONTRACTOR
ADDRESS Q t '�— N9 `•'V— -�Ati f
CITY " ' .ZIPl TEL. ZC
ARCH/ENG/ j
DESIGNER
Al �,, te LAS -EA
CITY , 06' = l tek ZIP e, TEL. a j 4?' — 1 z
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of porjury that I am exempt from the Contractor's State License Law for the reason(s)
indicated below by the checkmark(s), I have pieced next to the applicable Item{s) [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 permit to Nie a signed statementthaf he nr she
Is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 at Division 3 of the Business and Professions Code] or that he or she is exempt from Ilcensure and the basis for
the alleged exemption, Any vioiatlon of Sectlen 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
U 1, as owner of the property, or my employees with wages astheir sale compensation, will do U all of or U portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Cade: 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 that the 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.).
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 contracts for the protects with a licensed Contractor pursuant to the Contractors' State
License Law.).
LS I am exempt from licensure under the Contractor's State License law for the following Peasants};
Date: Sign:
By my signature below I acknowledge that, mceptfor my personal residence in which I must have resided for at least ane
year prior to completion of the improvements covered by this permitl cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed In Its entirety by iicensed 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 fallowing Weh site; httpAvww.IcgInfo,ca.gov/caIavv 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)
Of Division 3 of the Business} and Profeaslone Code. and
My license N in full force and effect.
LICENSE CLASS: ��e .) LIC. NO.: ' � `R 'p
E}(P. DATE: CONTRACTOR:-r-l�ap'w^4 46-•> ° 'rl`,,L . i'h:Lk�Vk=`">
WORKER'S COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 have and will maintain a Certificate of Consent to Salt -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 Insurance, as required by Section 3700 of the Labor Code, for
the performance oftFFhe work for which this permit Is Issued. My Worker's Compensation Insurance Carrier and
Policy Number are, f— �
CAR;IIE NUMDEQlIS L0�'� 'D -mac'' �Ia %.(i`'� i� L.�><� 94 ,'s;�4
POLIC
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS]
I certify that In the performance of the work far which this permlt Is issued, I shall not employ any person In any manner so asto
become subject to the Worker's Compansatien (Laws of California And agree that ff I should become subject to the Worker's
Componsafion W
e on! ftheLabor Code ,Ishag forfhwiihcomply wit those pmvlsions.
DATE: ^ i11PPL10ANT:.> yI.,3L{v—WARNING: FailWorker'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 cost of the compensation,
damages as provided for in section 3708 al the labor cede, 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, ON, 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 slate laws relating to building construction, and hereby authorize representatives of this county to
enter upontheabove-mentioned property for inspection purposes
PERMI Ef AME (PRINT} -
av-
SIG-KATURII PERMITTEE DATE
APPLICATION DATE: 1 sf P/C# pp' 11 �?
ISSUE DATE: l PERMIT# : E i �5�
TYPE CONST. OGC GROUP:
ii
Scope of Work t 9� d r rah➢ in iv -"A
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
LOU
Patio/Deck
LLL
ooi/Sp
ZRe
-Roof
Commercial
m
Valuation:
Adj. Area:
QUANTITY DESCRIPTION
FEE
c
U
c~a
wJ
w
z
in
a
a
r,
z
x
U
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
ES?.
MECHANICAL.:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:.
BASF:
PLOT PLAN:
ZONING CLEARANCE: s J
TOTAL FEES ier
COMMENTS:
7
P/C: °r PAID BY: I
RECEIPT# PAID Ely: T
VALIDATION:
VALIDATION:
WHITE —Department Copy, YELLOW— Finance Copy, PINK —Assessor Copy
CITY OF :D BAR
INSPECTION RECOR