HomeMy WebLinkAboutPR16-1543CITY 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 (909) 839-7027 FIRMLY
BUILDINGPERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
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CONTRACTOR
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DESIGNER
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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 checkmark(s), I have placed next to the applicable ifem(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 applicantfor 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 wfthSeelion
7000 of 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 violation of Section 7031.5 by any applicant for a peanit subjects the applicant to a civil penalty
of not 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 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 applyto 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 ContractorsState License Law does not apply to an owner of property who
builds or improves thereon, and who contracts forthe projects with a licensed Contractor pursuantto the Contractors' State
License Law,),
(J I am exempt from Bcensure under the Contractor's State License law forthe following reason(s):
Date: _._ Sinn:
By mysignature below I 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 pormIL1 cannot 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 Code is available upon request when this application is
submitted or at the following Web site: httplwww.leginfo.ca.gov/calaw,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 ofthe Business and Professlons Code, and my license is in full force and effect
LICENSE CLASS: LIC. NO.: .41,13
EXP. DATE: CONTRACTOR:
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the workfor 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 of the workiorwhich this permit Is Issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT B£ COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS),
I certify that into performance ofthe work for which this permit is Issued, I shall not employ anypersen in any mannerse w fo
become sub'ect to the Worker's Compensatlon Laws of California gree that if I shoukd become subject to the Worker's
Comp s n provi i n of Section 3700 of the Labor Cod shat forthe nth comply withthose provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage awful, 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,
i damages as provided for in section 37CO of the labor code, Interest, and attorney's Teas.
CONSTRUCTION LENDING AGENCY
i 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:
LENDER'S ADDRESS:
i
I certify that I have read this application and slate that the above information Is correct I agree to comply with all city and
I county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
i enter uponth above-entionedpropertyfor'spectienpurposes.
i 111
PERMITTEE NAME (PRINT)
OA
SIGNATURE OF PERMITTEE DATE
APPLICATION DATE: F]/c � P/C# /n
ISSUE DATE: ® PERMIT# : dk
TYPE CONST. OCC GROUP:
Scope of Work ir&le— a
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ, AREANALUATION
SFR/ADD/REM
Garage/Carport
N2
Patio/Deck
LU
LL
Pool/Spa
ZRe
-Roof
Commercial
[D
valual iorr. Adj. Area:
QUANTITY DESCRIPTION FEE
J
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U
W
w
l o vie Vaive
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=
a
i face b Gr
J
a
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Q
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CONSTRUCTION: t
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY PIG:
ENERGY PERMIT:
RETENTION FEE: .
PRE -ALT FEE:
BASF: -
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES -71 4A
COMMENTS:
PIC: a!!;� PAIDBY: VALIDATION
RECEIPT # _ PAIDBY: VALIDATION:
WHITE Department Copy, YFLI Finance Copy, PINK —Assessor Copy
COMMENTS: