HomeMy WebLinkAboutPR17-0794-
CITY OF DIAMOND BAR
! i DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21814 Copley Drive, Diamond Bar, CA 41765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
JOB SITE ADDRESS
APN LOT TRACT
OWNER
ADDRESS �� r cit *'
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CITY woy,,l 0 r ZIP ' P7 6,;, - EL. -7 0S_
APPLICANT TEL,
CONTRACTOR 80 S_'C�s� v
ADDRESS _ � ctf� V&,
CITY Moll-: ^ ZIP 106' -2- 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 reason(s)
Incilcated below by the checkmaA(s), I have placed next to the applicable items) [Section 7031 Z, Business and
Professions Code: Any city or county that requires a permit to construct, All improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicant for the permit to file n signed statement that he or she
is licensed pursuant the provisions of the Contractor's State License Law (Chapterg) 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. Anyvlolafion of Section 7031.5 by any applicant for a permitsubjectsthe appidanito a civil penalty
of nat more than five hundred dollars ($500).
U I, as owner of the property, or my employees with wages as their sole compensation, will do U all of ori) 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 properly 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-Rullder will have the burden of proving that it was not built
or improved for the purpose of sale.).
11, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Perfessfons 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 to the Contractors' Stats
License Law.).
U I an exemptfrom licensure under the Contractor's State License law forthe following reasorl
Date: Sign:
By my signature below l acknowledge that, exceptfor my personal residence in which I must have resided for at least one
year prior to completion ofthe improvements covered by this permit,] cannot legally self a structure that; have built as an
owner -builder if it has not been constructed in its entirely by licensed contractors. 1 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 tire following Website: hltplwwwfeginto.ca.gov/calaw.htmk.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (cornmendrig with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force and effect.
S,Cr!c
LICENSE CLASS:. LIC. NO.: 17 C,
EXP. DATE: %' a -t% CONTRACTOR: Sr, G L
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I '✓ I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
I Section 3706 of the Labor Code, forthe performance of the work for which this permit Is issued.
y I have and will mainta€n Worker's Compensation Insurance, as required by Section 3700 blithe Labor Code, for
the performance at the workfor whlch this permit is issued. My Worker's Compensation Insurance Cartier and
i
Policy Number are:
r CARRIER
POLICY NUMBER
i
(N -IIS 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 forwhich this permit is issued, I shall not employ any person in any manner so as to
become subjectto the Workers Compensation Laws of California. And agree that H I should become subject to the Worker's
Compensgtion provisions of Section 3700 of the Labor Code, Ishall forfhwth comply with those provisions.
_ DATE: � m d APPLICANT: fi 0 11 �s
WARNING: Failure to secure Worker's Compensaflon coverage is unlawful, and shall subject an employer to criminal
a penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
5 damages as provided for 1n section 3703 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENGY
i 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.),
LENDER'S NAME:
LENDER'S ADDRESS:
- I certify that I have read thls application and state that the above information is correct I agree to comply with ah city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
S enter upon the above-mentioned property for inspection purposes.
PERMITTEE NAME (PRINT)
41, a
-
SIGNATURE OF PERMITTEE__ DATE
APPLICATION DATE:
ISSUE DATE: ,
TYPE CONST.
Lf P/C# _
PERMIT# : I
OCC GROUP:
Scope of Work
# DWEL. UNITS
-
if STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATiON
SFFI/AD❑/REM
Garage/Carport
w
Patio/Deck
LU
LL
Pool/Spa
ZRe
-Roof
Commercial
Valuation;
Adj. Area:
QUANTITY
DESCRIPTION FEE
U
ui
w
-
c�
a
m
a
ca
z
U
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TQTALFEES.-
COMMENTS;
PIC:
RECEIPT# 1
PAIL) BY: VALIDATION:
PAID BY: VALIDATION:
WHITE —Department Copy, YELLOW — Finance Copy, PINK—Assessor Copy
14,
COMMENTS: MENTS: