HomeMy WebLinkAboutPR16-2470CITY OF DIAMOND BAR
DEPARTMENT OF COMM UNIT & DEVELOPMENT SERVICE+ S r
. - 21810 Copley Drive, Diamond Bar, CA 91765 x PRESS
(909) 839-7020 Fax_ (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbancom building@diamofidbarca.gov
APPLICATION DATE: fa Off �1 P/C# 'fi -�
111-20
SITEADDRESS EP s w. s7t .. (C3 j F't (10Z
ISSUE DATE: � / i�' PERMIT#
LOT TRACT
�vvNER i- de— 1 r TYPE CONST._ OCC GROUP:
ADDRESS I
CITY fqMs A) -ZIP l'TEL. 2` LID- 0'7`7
APPLICANT {Z4A1 & TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
DESIGNER v i�V 5 C-0
DESIGNER 4
ADDRESS
CITY &k -T ZIP ® TEL
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 below by the checkmark(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 permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Cantractor's State License Law (Chapter 9) Commencing with Section
r 7000 of Division 3 of the Business and Professions Codel orthat he or she is exempt from licensure and the basis for
' the alleged exemption. Any violation of Section 7031 Z by any applicant for a permit subjects the applicarri a dvil portalty
of not more than five hundred dollars ($500).
I U1, as owner of the property, army employees with wages aslheirsolecompensaidon,will doUall ofor(-)portions
} of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The
i Cont astors' State License Law does not applyto an owner of property who, through employees' or personal effort, builds
or improves the property, provided that to Improvements are not intended or offered for sale. If however, the building or
improvement is sold within one year of completion, the Owner-Bulicier will have the burden of proving that It was not built
' or Improved for the purpose of sale.).
L)1, 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
builds or Improves thereon, and who contracts forthe projectewhh a licensed Contractor pursuanttothe Contractors' Stale
5
License Law.).
( ] I am exempt from lic sure under the Can or&byrmit,l
la for
reascal
Date:�ef� -D � Ign: _�-___--
7 By my signature below i acknowleage that, except en a have resided for at least one
5 year pdo,to completion of the improvements covered annot ucture that I have bullt 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 7D44 of the Business and Professions Code is available upon request when this application is
a submitted or et the following Web site: httplwvvw,loginio.ca.gov/calaw.htmi.
LICENSED CONTRACTOR'S DECLARATION
Ll
I hereby affirm under penalty of perjury that I am licensed under provisions or Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force and effect.
0
LICENSE CLASS: LIC. NO.:
z EAP. DATE: CONTRACTOR:
WORKER'S COMPENSATION DECLARATION
U l HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Cerllficate of Consent to SelfInsurefor Worker's Compensation, as provided by
' Section 37CO of the Labor Code, for this performance of the work for which this permit Is issued.
7
� I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Cade, for
the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER
:5 POLICY NUMBER
n (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LE55).
I certify that in the performance ofthe worktor which this permill Issued, I shall not employ any person in any manner so as to
y become subject t0 the Worker's Compensation Laws of California. And agree that If I should become subject to the Worker's
Compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with those provisions.
i DATE: APPLICANT:
sWARNING: 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,
:353 damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
i CONSTRUCTION LENDING AGENCY
I hereby affirm under penally of perjury that there is a Construction Lending Agency for the performance of the work for
3-- which this permit is Issued (Sec. 3097, Clv. C,),
LENDER'S NAME:
LENDER'S ADDRESS:
w
� ! certilythai I have read this application and slate that the above information is correct. l agree to comply with all city and
z county ordinances and state laws relating to building construction, and hereby authorize representatives ofthis county to
n enter upon the abave-merdlonedproperly for inspection purposes.
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_ SlGNATU F P �1)
DATE
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Scope of Work r' -'
# DWEL. UNITS _ # STORIES # BEDROOMS
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DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck "�
Pool/Spa
Re -Roof
Commercial
Valuaiivn: Adj. Area:
CONSTRUCTION:'
PLAN REVIEW: I
QUANTITY DESCRIPTION FEE
ELECTRIC:
PLUMBING:
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ENERGY PERMIT:
RETENTION FEE:?
PRE -ALT FEE:
BASF:_
PLOT PLAN:
ZONING CLEARANCE:
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TOTAL FEES
COMMENTS':
CONSTRUCTION:'
PLAN REVIEW: I
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
( a m
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:?
PRE -ALT FEE:
BASF:_
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS':
PIC: ' 2� 3A` /=�'a' PAID BY: °1��/ r�-'S
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RECEIPT u OL PAID BY:
VALIDATION: V
VALIDATION:
WHITE: — Department Copy, YELLOW -- Finance Copy, PINK — Assessor Copy
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Job Address: t
Dear Property Owner;
Ill �l IOND
Building & Safety Division
21810 Copley Drive
Diamond Bar, California 91765
(909) 839-7020 Fax (909) 861-3117
M
X
An application for a building permit has been submitted in your name stating yourself as the builder of the
property improvements specified.
For your protection, you should be aware that as "owner -builder° you are the responsible party of record on
such a permit. Building permits are not required to be signed by property owners unless they are personally
performing their own work. If your work is being performed by someone other than yourself, you may protect yourself
from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business
license from the City of County_ They are also required by law to put their license number on all permits for which they
apply.
If you employ or otherwise engage any persons other than your immediate family, and the work (including
materials and other costs) is $500.00 or more for the entire project, and such persons are not licensed as contractors
or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal government as an employer and you are
subject to several obligations including state and federal income tax withholding, federal social security taxes, workers
compensation insurance, disability insurance costs, and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially
serious with respect to workers compensation insurance.
For more specific information about your obligations under.the federal law, contact the Internal Review Service
(and if you wish, the U.S. Small Business Administration). For more specific information about your obligations under
State law, contact: the Department of Benefit -Payments and the Division of Industrial Accidents.
If the structure is intended for sale, the property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees, without a licensed contractor or subcontractor, only
under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "owner -builder" building
permit, erroneously implying that the property owner is providing his or her own labor and materials personally.
Building permits are not required to be signed by the property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors State License Board at
9821 Business Park Drive, Sacramento, CA 95827, MM.csib-ca.gov or at (800) 321 -CSL B (2752).
Please complete and retum the enclosed "Owner -Builder" verification form so that we can confirm that you are
aware of these matters. The building permit will not be issued until the verification is returned.
Attention Property Owner:
An "Owner -Builder" building permit has been applied for in your name and bearing your signature.
Please complete and return this information at your earliest opportunity to avoid unnecessary delay in processing and
issuing your building permit. No building permitwill be issued until this verification is received by us.
1. 1 personally pl provide the major labor ad materials for construction of the proposed property
improvement e r no).
2. I 6avethave not) t i- ` signed an application for a building permit for the proposed work.
3. 1 have contracted with the following person (firm) to provide the proposed construction:
Name Address City
Phone Contractors License No.
4. l plan to provide portions of the work, but i have hired the following person to coordinate, supervise and
provide the major work:
Name Address City
Phone Contractors License No.
5. 1 will provide some of the work but I have contracted (hired) the following persons to provide the work
indicated:
Name Address Phone Type of Worts
a
Date t U I I I I-
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified ate ' �� cf � , ® ._ ,.. g C
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by laving this permit issued in your name as the Owner -Builder.
We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you,
the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGEMENT AND VERIFICATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
41. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the' onstruction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. 1 understand that I may
pro myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name
instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
to value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered
an "employer" understate and federal law.
_ I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is pe rrmed under contract with a licensed general building Contractor.
18. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects
in the workmanship or materials.
g. I understand I may obtain more information regarding my obligations as an "employer' from the Internal
enue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) orwww.cslb.ca.aov for more information about licensed contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
81 the party legally and financially responsible for proposed construction activity at the following address:
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
b��all applicable laws and requirements that govern Owner -Builders as well as ern ployers.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
Information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist
your with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee
of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a
permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those
Contractors are properly licensed and the status of their workers' compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuing the permit.
Note: A copy of the property owner's driver's license, farm notarization, or other verification acceptable to the agency is
required to be presented when the permit is issued to verify the property owner's signature.
Signature of Properly Ownr: Date:1 tsl
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