HomeMy WebLinkAboutPR17-865le,CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
Copley Drive, Diamond Bar, CA 91765 PRESS
(409)839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMITAP!'LICATION www.cityotdiamondbar.Com building@diauoodbarca.gov
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APPLICANT TEL.
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ADDRESS
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OWNER -BUILDER DEGLARATION
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 checkmark(s), I have placed next 10 the applicable Items) [Section 7031.5, Business and
z Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
LU 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
EO 7000 of Division 3 of the Business and Professions Code] or that he arshe is exempt from licensure and the basis for
SQ the alleged exemption. Any violation of Section 7031,5 by any applicantfora permitsubjects the appllcantlo acivil penalty
IS of not more than five hundred dollars ($500).
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®(Jl,asawnerattheproperty,ofMyemployeeswithwagesastheirsolecompensat€on,willdo(_)allofor(jportions
Q of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Cade: The
Lu Contractors' Stale License Law does not apply to an owner of property who, through employees' or personal effort, builds
22 or improves the property, provided that the improvements are not Intended or offered for sale. R however, the building or
oimprovement Is sold within one yearof completion, the Owner -Builder will have the burden of proving that it was not built
L' orimproved for the purpose at sale.).
z0I, 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
Y builds or improves thereon, and who contracts fortheprojects with alicensed Comiroc€0rpursuanttolheContractors'Slate
cc License Law.).
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� (.-) I am exempt from 1€censure under the Contractor's State License law forthe fallowing reason(s):
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Date: Sign:
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By my signature below I acknowledge that, exceptfor my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by this perms€,€ cannot legally sell a structure that I have built as an
� owner-huildar it It has not been constructed In its ersUrety 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 applicaUen is
cD submitted or at the following Web site: ht[pfvww,teglnfD.ca.gov/calaw.htMi-
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U LICENSED CONTRACTOR'S DECLARATION
mI hereby affirm under penally of perjurythatl am licensed underprovislons of Chapter 9 (commencing with Section 7000)
of DMslar 3 of the Business and Professions "andrise is In Idl force and effect.
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5Q LICENSE CLASS: LIC. NO.:i
EXP, DATE: CONTRACTOR: � i
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o WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF 711E FOLLOWING DECLARATIONS:
c3 i have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 37OG of the Labor Code, forthe performance of the workier which this permit is Issued.
7 I have and will maintain Worker's Compensafion Insurance, as required by Section 3700 of the Labor Code, for
athe performance of the work for which this permit Is issued. My Worker's Compensation Insurance Carderand
Po€icyNumchore: ?
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CARRIERCT
c? POLICY NUMBER
(FIRS SECTION NEED NOT RECDMRMD FTHEPERMITISFORUNEHUNDREDDOLIAAS $100 DRLFS5).
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ED Icerfifythatinthe performance ofthe workforwhich this permit isissued, Ishall not employ any pew inany manner sow to
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become subject to the Worker's Compensation Laws of California. And agree Wit I should home subjecito the Wakens
L_uj COmpensafta provisions of Section 3700of Ole tabor Code, I shall forthwith amply with those Provisions-
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DATE APPLICANT:
WARNING: Fallur , to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
LU penalties and civil fines up to one hundred thousand dollars ($100,0DO), in addition to the cost of the compensation,
o damages as provided for in section 3700 of the labor code, Interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
Lu 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.).
F- LENCER'S NAME:
LENDER'SADDRFSS:
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n I certify that I have read this application and state that the above Information Is correct. I agree to comply with BE city and
z county ordinances and slate laws relating to building construction, and hereby authorize representatives of this county to
o enter upon the above-mentioned property for inspection purposes.
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PERMITTEE NAIVE (PR1ryt]
SIGNATURE OF PERMIrrEll DATE
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APPLICATION DATE: li P/C#
ISSUE DATE: f PERMIT# : P
TYPE CONST,
OCC GROUP:
Scope of Work O DVe- !a
If DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. LL. FACTOR PSE ADJ. ARFANALUATION
SFFIYADD/BEM
Oarage/Garport
Pat€o/Deck
Pool/Spa
Re -Root
Commercial
Valuation: Adj. Area:
CONSTRUCTION:
PLAN REVIEW:
QUANTITY DESCRIPTION
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Mi226
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INSPECTION FEE:
ISSUANCE:
SMIP:
17
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ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
-.-.
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/G:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
1 TOTAL FEES
COMMENTS:
P/C: PAID BY: VAL€DATION:
RECEIPT Y 3458(6- PAID BY:"" 19 7 VAL€DATION:
WHITE — Department Copy, YELLOW --- Finance Copy, PINK — Assessor Copy