HomeMy WebLinkAboutPR17-9983_ ...: CITY OF DIAMOND BAR
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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
;Ugsi BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamond.barca.gov
1135 �L iNi� ®C fr' 1Q� . APPLICATION DATE: ®7 a5-/7 P/C#
JOB SITE ADDRESS r�
ISSUE DATE: FJI J—PERMIT# : _C 11 �C1 S
5 APN LOT TRACT
J OWNER ARVILLE �IOHNSON TYPE CONST. OCC GROUP:
ADDRESS 113 Fl-1"Vrk0" I�0
L CITY ZIP 91765TEL.'i ` €360 — 66
APPLICANT _8�� M,4R7'J FL. 6"_All
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CONTRACTOR
o ADDRESS 507 AZ USA-
CITY Loq PUE/tITE- ZlP 7EL.
ARCH/ENG/
UDESIGNER
ADDRESS
n CITY ZIP—TEL.
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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)
L indicated below by the cheekmark(s), I have placed next to the applicable items) [Section 7031.5, Business and
Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, Or repair, any
i structure, prior to its issuance, also requires the applicant for the permitto file a signed statementthat he or she
» is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
n 7006 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 appficantfor a permit subjects the applicantto a civil penalty
r of not more than five hundred dollars ($500).
U} I, as owner of the property, army employees with wages astheirsole compensation, will do all of or (-} portions
a 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 oflered for sale, if however, the building or
Improvement is sold wlthln one year of completion, the Owner -Builder will have the burden of proving that It was not built
or Improved forthe purpose of sale,}.
cD U) I, as owner oll property, am exclusively contracting with licensed Contractors to construct the project (Section
1044, 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 cortracts forthe projects wt a licensed Contractor pursuant to the Contrautors' State
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License Law.).
3� U) I am exempt from licensure onderihe Contractor's State License law forthe following reason(s):
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Date: Sign:
By my signabrra b6 ,v I acknowisdge that, except for my personal resilience in which most have resided for at leant one
Year prior to completion of the improvements covered by this permlt,l 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 i.s.,...,..
cD su]arrItted or all following Web Site: httpfwww,logirfo-ca-DOV/Cal3w.htrnI
v LICENSED C6NTRACTOR'S DECLARATION
mI hereby affirm under penalty of perjury that 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.
i DATE T CONTRACTOR: FIAI
o WORKER'S COMPENSATION DECLARATION
i HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
o I he" ad will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
J ion 3700 of the Labor Code, for the performance of the work for which this permit Is issued.
I have and will maintain 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 Carrier and
Policy Number are:
LuCARRIER S�TfC ����
CD POLICY NUMBER
(THIS SECTION NEED NOT BECOMPLLfED IFTRE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
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I eertftythat In the performance oftheworktor which this permit k issued, I shall not employ any person In any mannerso alto
on become subject to the Worker's Compensaton Laws of California. And agree that if I should become subject to the Worker's
J"mpen""on provsions of-S7pction 3700 of the Labor I shall fo thwith comply with revisions.
LL DATE: O7 ':3� '1 RPPLICANT:
WARNING Failure to secure Worker's Coope t coverage is unlawtui, and shall subject an employer to criminal
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penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
cD damages as provided for in section 5708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
w 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 (Sac. 3097, Civ. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
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0.- 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 laws relating to building construction, and hereby authorize representatives of this county to
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o enter upon the above-mentioned property for inspection purposes.
OL-04KE M PAT dy
PERMITTEE NAM PRS
cn —
x SIGN ERMiTTEE DATE
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So�e of Work
Teill OFF illOl HVil 'E
`O. S. S . P Ywc1® 61Vb 304f A. 5.T M FiF.I
NEx7- 30 VR. cc4ss "Alevc,,4r5
# DWEL. UNITS # STORIES a # BEDROOMS
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DESCRIPTION SQ. FT. FACTOR PSF ADJ. ARFANALUATION
SPR/ADD/REM
Garage/Carport
Patio/Deck
Pool
He -Roof 2_p]
Commercial
Valuation: 1C). 81M 00 Adj. Area:
CONSTRUCTION:
PLAN REVIEW:
QUANTITY DESCRIPTION FEE
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ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
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PLOT PLAN:
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CONSTRUCTION:
PLAN REVIEW:
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ELECTRIC:
PLUMBING:
MECHANICAL
INSPECTION FEE:
ISSUANCE:
SMIP:
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ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
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BASF:
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PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS: _
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P/C: PAID BY: VALIDATION: � /
RECEIPT 4 PAID SY: j,"',_/00 C VALIDATION: I� 0
WHITE— Department Copy, YELLOW— Finance Copy, PINK—Assessor Copy
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COMMENTS: