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HomeMy WebLinkAboutPR16-2619CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES - 21810 Copley Drive, Diamond Bar, CA 91765 PRESS (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (409) 839-7027 FIRMLY +BQ� BUILDING PERMIT APPLICATION www.cityoFdiamondbar.cam buildiag@diatnondbarca.gov Jd� SITE ADDRLSS t� 0 �,Y%yt Pd' i AILM"NSA &"Y APN LOT TRACT OWNER N' ADDRESS b �'t+t yl CITY W- cts pp ZIP TEL ��'- APPLICANT �" dL's'i L H TEL. &6 6r7r) 0 dZ CONTRACTOR ADDRESS CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS ii i ' iw'rfd r CITY t ZIP A r't 4 TEL. 11)) 3 �t�% 2 6a�$ cti l 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 clreckmark(s), I have placed next to the applicable items) [Section 7031.5, Business and Professions Cade: 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 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 SWUM 7000 of Division 3 of the Business and Professions Code] or that he or she is exempt from licensure and the basisfor 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), las owner of the property, or my employees with wages as their sole compensation, will do Wall of crU portions of the work, and the structure is not intended or offered for sale (Section 7D44, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal efforts 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 at property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Cantractors' State License Law.), U I am exemptfrom Feensure under the Contractor's State License law for the following conson(s): Date: by S1gn: i! By my signature teiow I aakn wledge/...?i except for my psrsora! reside io �•rhiah f must have resided for at least one year prior to completion of the improvements covered by this pam l not 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 Cade is available upon request when this application is submitted or at the following Web site: http/www.leginfo.ca,guv/calawhtml. LICENSED CONTRACTOR'S DECLARATION" } I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 701 of Division 3 of the Business and Professions Code, and my [!cense is in full force and effect. LICENSE CLASS: LIC.NO.T EXP. DATE: CONTRACTOR: WORKER'S COMPENSATION DECLARATION I HERESY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: 5 1 have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by t Section 3700 of the Later Code, forthe performance of tho work for which this permit is issued. I have and wili maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My Worker's Compensation insurance Carrier and Policy Number are: a CARRIER POLICY NUMBER o (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS). I cedifythat in the performance ofifte work forwhich this permit is issued, [shall not employ any person in any manner so as to � become subject to the Worker's Compensation Laws of California, And agree That if I should become subject to the Worker's LJ Compensation provisions of Section 3700 of the Labor Cede, I shall forthwith comply with those preuislons. L DAic, APPLICANT: WARNING: Failure to secure Worker's Compensation coverage 1s unlawful, and shall subject an employer to criminal u 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 of the labor code, interest, and attorney's fees. i CONSTRUCTION LENDING AGENCY v 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, r LENDER'S ADDRESS: i I certify that I have read this application and state that the above information is correct. I agree to comply with all city and z county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the ahove-mentioned property for Inspection prpases. D n PERMITTEE NAME (PRINT) 7 Jc / = SIGNATURE O PEA A DA APPLICATION DATE: 3i pk � t —F/C# Qom— ISSUE DATE: f/ PERMIT-#: — 7-11`1 TYPE CONST. OCC GROUP: Scope of Works 1s,,1. -'l n! l,aj, ^es�,e i ,i':- - t,}i; €y; r➢ro e sz#z i r . a # DWEL. UNITS _._ # STORIES �� 4 BEDROOMS DESCRIPT{ON SQ. FT. FACTOR PSF ADJ. AREA VALUATION SFR/ADDIREM Garage/Carport Patio/Deck Pool/Spa Re -Roof Commercial MECHANICAL: INSPECTION FEE: ISSUANCE: - SMIPI q, 5 Valuation: K Adj. Area: QUANTITY J v w z ULonger than the day CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: - SMIPI q, 5 ENERGY PIC: ENERGY PERMIT: RETENTION FEL: PRE -ALT FEE: 9' 00 BASF: Z, 00 PLOT PLAN' ZONING CLEARANCE: TOTAL FEES COMMENTS: PIC: :s �'' PAID BY: 4 f gg VALIDATION: li RECEIPT 8 .3q 14-1 PAID BY: �% I l� VALIDATION: LC_ WHITE— Department Copy, YELLOW — Finance Copy, PINK— Assessor Copy COMMENTS: J Job Address: :-? � 5-3 o iy-C t ' 6, Dear Property Owner- An wnerAn application for a building permit has been submitted in your name stating yourself as the builder of the property improvements specified. For your protection, you should be aware that as `owner-builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City of County. They are also required by law to put their lioense number on all permits for which they apply. If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $500.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes, workers compensation insurance, disability insurance costs, and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers compensation insurance. For more specific information about your obligations under.the federal law, contact the internal Review Service (and if you wish, the U.S. Small Business Administration). For more specific information about your obligations under State law, contact the Department of Benefit-Payments and the Division of Industrial Accidents. If the structure is intended for sale, the property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "owner-builder" building permit, erroneously implying that the property owner is providing his or her own labor and materials personally. Building permits are not required to be signed by the property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors State License Board at 9821 Business Park Drive, Sacramento, CA 95827, www.csib.ca.gov or at (800) 329 -CSLB (2752). Please complete and return the enclosed "Owner-Bullder" verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. MOND BI IIL f� Attention Property Owner. An "Owner -Builder" building permit has been applied for in your name and bearing your signature. Please complete and return this information at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received by us. 1. I personally plan to provide the major labor and materials for construction of the proposed property improvement (yes or no). r 2. 1 (aihave not) signed an application for a building permit for the proposed work. 3. 1 have contracted with the following person (firm) to provide the proposed construction: Name _ Address City Phone Contractors License No. 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name Address City Phone Contractors License No. 5. 1 will provide some of the work but I have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed Property Owner Bate 0� _ NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted'n your name li tin yourself as the builder of the property improvements specified at r` �� b - We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner- Builder_ We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGEMENT AND VERIFICATION DIRECTIONS: Read and initial each statement below to signify you understand or verify this information. 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - B.0 der" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. I understand building permits are not required to be signed by property owners unless they are responsible for e construction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner -Builder"' I am the responsible party of record an the permit. I understand that 1 may p teat myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own, 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license tubers on permits and contracts. 5. l understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered An "employer" under state and federal law. S. l understand if I am considered an "employer" under state and federal law, I must register with the state and eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7.1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family re der ial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by 4 ansed subcontractors and the number of structures does not exceed four within any calendar year, or all of the worts is performed under contract with a,licensed general building Contractor. & 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for rthe nancial or personal injuries sustained by anysubsequent owner(s) that result from any latent construction defects workmanship or materials. 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal venue Service, the United States Small Business Administration, the California Department of Benefit payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1800-321-CSLB (2752) or www.cslb.ca.o_ov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that 1 a the party legally and financially responsible for proposed construction activity at the following address: 11. i agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide b all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the I ormation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If ou contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or empioyee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Signature of Property Owner. i- Date: