HomeMy WebLinkAboutPR17-12362s
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CITY 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
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com buildiidg@dia
JOB SITE ADDRESS �� t" f�{�
APN LOT TRACT
OWNER �lKC2�tr j�t1
ADDRESS 1
C€TY zipoAnU TEL. C' C 36
APPLICANT LAS A '&' QN1Xr'_k TEL. (WR S`ri-?2'.5
CONTRACTOR
ADDRESS (°} 1 �� ' -C
CITY ,)t rife ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER 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 tel [Section 7031.5, Business and
Professians Cade: Any city or county that requires a permit to construct, aster, 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 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. 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(.
11, as owner of the property, or my employees with wages as theirsole compensation, will do U all of or (j 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, holds
ar 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.).
{-) 1, as owner ofthe 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
builds or Improves thereon, and who cortractsforthe projects with a licensed Contractor pursuantto the Contractors' State
License Law.).
U-) t am exempt from licensure underthe Contractor's Slate License law forthe fallowing reason(s):
Date: Slgn:
By my signature below k acknowledge that, exception my personal residence In which I must have resided for at least one
year priorto completion of the improvements covered by this perm[Ul 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 cr at the following Web s€te: ht5plwww.leginfo.ca.govlcalaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjurythat I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force and effect.
o LICENSE CLASS: LIC. NO.: Il I Wit""
z EXP. DATE: CONTRACTOR
a
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
o I have and will maintain a Certificate of Consent to SelfInsurefor Worker's Compensation, as provided by
¢ Section 3700 of the Labor Cade, forthe performance of the work for which this permit is issued.
C3 I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Cade, for
a the performance of the workfor which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
z CARRIER
POLICYNOM13ER ! -
(fH15 SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certitythat in the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to
z become subject to the Workers Compensation Laws of Caliiomia. And agree Shat if I should become subject to the Worker's
i Compensation provisions of Secdon 3700 ofthe Labor C
If ith comply with those provisions,
j
DATE: -^ i " APPLICANT: w
i WARNING Failure to secure Worker's Compensation coverage is i lawful, and shall subject an employer to criminal
i penalties and civil fines up to one hundred thousand dollars ($11 In addition to the Cast of the compensation,
i damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
i k 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 state that the above Information's correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives ofthis county to
enter upon the above-mentioned property for Inspection purposes.
PERMITTEE NAME PRI _ re°'>
SIGNATURE OF PER DATE
APPLICATION DATF: S/ �'I P/C#
ISSUE DATE: ��� PERMIT# : 'r\R, �_l — k'a:-:
TYPE CONST. OCC GROUP:
Scope of Work
# DWLL. UNITS 9 STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSE ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carpor[
OL
Patio/Deck
LLL
Pool/Spa
zRe
-Roof
a
Commercial
m
Valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
4
_
yC ;
J
�.V
w
co
a
m
U
z
Q
x
v
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE: (®
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 4 PAID BY: VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK Assessor Copy
COMMENTS: