HomeMy WebLinkAboutPR17-614CITY OF DIAMOND BAR
DEPARTMENT Ola' 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.cifyofdiarnondbar.com building,)diamondbarca,gov
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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 reasons)
indicated helow by the checkmark(s), I have placed next to the applicable item{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 applicant for me permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 91 Commencing with Section
7000 of Division 3 of the Business and Professions Cade) or that he or she Is exemptfrom 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).
{ j I, as owner of the property, or my employees with wages as Meirsole compensation, will do L) all of or U porlions
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, 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 completton, the Owner -Builder will have the burden of proving that it was not built
or improved for the purpose of sale.}.
O 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 veno
builds or Improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State
License Law.).
(-) I am exemptfrom licensure under the Contractor's State License law tar the following reason(s):
Date: Sign:
By my signature below I acknowledge that, exceptfor my personal residence in which € must have resided for at least one
year prior to completion ofthe improvements covered by this permit,I 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 atthe following Web site: http/www.loginfo.ca.gov/caiaw.h"l.
LICENSED CONTRACTOR'S DECLARATION
€ hereby affirm under penalty of'polury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
Of Division 3 at the Business and Professions Code, andmyIII is 11
11 full force and effect.
LICENSE CLASS: UC. NO.: t r'
EXP. DATE: �J CONTRACTOR:
WORKER'S COMPENSATI N DECLARATION
I HERE13Y AFFI R M UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAR0N5:
I have and will maintain a Certiticate of Consent to Sett -Insure for Worker's Cempensation, as provided by
Section 3700 of the Labor Code, for the performance of the work torwhich this permit is issued.
I have and will mail Worker's Compensation Insurance, as required by Section 3700 ofthe Labor Code, for
the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carder and
Policy Number arg: ------
CARRIER�dn--�''
POLICY NUMBER 61.
(PHIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $190 OR LESS).
I certify that in to performance ofthe work for which this permit is issued, I shall not employ any person In any manner so ES to
become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to the Worker's
Compensation provisions otSection 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, 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,
damages as provided for in section 3708 of the labor code, interest, and attorney'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 this permit's issued (Sec. 3097, Civ. C).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state thatthe above information Is correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
enter upon the above-merdloned property f�,or Inspection purposes,
PERMITTEE NA '(PRINT)
SIGNATURE or PERMITTEE DATE
APPLICATION DATL F1
ISSUE DATE: —PERI
TYPE CONST.
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PIC# PR N7 — 4.z L
OCC GROUP:
Scope of Work ���pp� io
w# DWEL. UNITS # STORIES
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# BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF
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Valuation:
Adj. Area:
QUANTITY
DESCRIPTION FEE
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: PAID BY:
RECEIPT # PAID BY:
VALIDATION:
VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
COMMENTS: