HomeMy WebLinkAboutPR17-12920llIrl��I ND BAR
CITY OF DIAMOND BAR ,•
i
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Uilr, CA 9.1765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION wrvrv.cityofdiamondbar.conL building@diamondbarca.gov
JOB SITE ADDRESS rM 0(4 lid �4 1+n
APN LOT TRACT
OWNER 1111114 71
ADDRESS 4Y1lt
CITY ZIP TEL.
APPLICANT TEL.
CONTRACT R Y1 1-�
ADDRESxb�_M_
C OGCITYIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUTLOER DECLARATION
1 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 to the applicable Item(s) [Section 7031.5, Business and
Professions Code: Any City er 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 pursuantto the provisions of the Contractor's State License Law (01apter9) 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. Anyvlolathm of Section 7031.5 by anyspplicantfor a permit subjects the applicant to acivil penalty
of not more than five hundred dollars (S500).
U I, as owner of the property, or my employees with wages as their sole compensation, will do U aff of or () portions
of the work, and the structure Is not Intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, bunds
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
bullds or Improves thereon, and who contractsforthe projaclswith a licensed Contractor pursuant lathe contractors' State
Hconne Law.).
(.) I am exempt from licensure under the Contractor's State License law for the following reason($):
Date: Sign:
By my signature below I acknowledge that, except for my parsonaf residence In which I must have reslded for at least one
year priorto completion of the Improvements covered by this permit,[ cannot legally sell a structure that 1 have built as an
owner -builder R 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 Cede Is available upon request when this application Is
submitted Cr at the following Web site: hUplwww.leginio.ca.govfcalaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby afOrm under penalty of perjury that I am licensed under prGwslons of Chapter 9 (commencing with Section 7000)
of Division 3 of the
Business and Professions Coda, and my license Is in full force and effect.
LICENSE CLASS: ` LIC. NO.: 0 TJr
tXP. DATE; CONTRACTOR:
WORMR'S COMPENSATION T10N
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOL 0 DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
--/Sectlen 3700 of the Labor Code, for the performance of the work for which this permit Is Issued,
—have and will maintain Worker's Compensation Insurance, as required by Scutari 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My Worker's Compensation fnewance Carrier and
Pofty Number are:
CARRIER ly orf f 0r
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF TIE PERM(T IS FOR ONE HUNDRED DOLLARS $100 08 LESS).
I certify that In the performance of the work for which this permit Is issued, I shall rat employ any person In any manner so as to
became sub]ect to the Worker's Compensation Laws of California. And agree that d I should became subject to the Worker's
Compensation provisions of Seaton 3700 of the Labor Cade, I shall todhwifh campy with those pmvl5lons.
HATE; APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines ug to one hundred thousand dollars (S100,000), In addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, Interest, and allornay'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 Vila 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 I wa r lag to bullding construction, and hereby authorize representatives of this county to
enter upon the above -m perty for inspection purposes.
PERMITT (PRINT) h -T%VV'fi 9)1/-r-/7
SIGNATURE OF PERMITTEE ` �r DATE
APPLICATION DAT : I S P/C#
ISSUE DATE: 5 PERMIT# :
TYPE CONST. OCC GROUP:
Scope of Work i -c )L
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck
LL
Pool/Spa
ZRe
-Roof
Commerclal
valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
J
a
�i
w
M
J
a
c�
2
a
x
CONSTRUCTION:
PIAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE: 3
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
P/C; PAID BY: VALIDATION:
RECEIPT # 3 UJ ar PAID BY: �VALIDATION:! (1 _,..,,.—
WHITE— Department Copy, YELLOW — Finance Copy, PINK ---Assessor Copy
�. D114MOND BAR
INSPECTION RECORD