HomeMy WebLinkAboutPR16-2218 (8)i
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7420 Fax: (909) 851-3117 Building Inspection Hotline (909) 839-7027
FIRMLY
BUILDING PERTTAPPLICATION t
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JOB SITE ADDRESS
APN LOT TR T r
OWNER
ADDR
CITY ZIP EL,
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APPLICANT TEL.
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CONTRACTO
ADDRESS C -
CITY P L.
ARCH/ENG/DESIGN R
ADDRESS
CITY Zip TEL.
oWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the ContraCter'e State License Law for the reasons)
indicated below by the checkmark(s), I have placed next to the applicable itarn(s) ]Section 70315, 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 the permit to file a signed statement that he or she
is licensed pursuant to the provisions blithe Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division a of the Business and Professions Code] or that he or she is exempt from liceusure and the basisfor
the alleged exemption, Any violation of Section 7031.5 byany applicant for a pemtitzubjects the applicantta aclvil penalty
of not more, than five hundred dollars ($500).
L) I, as owner of the property, or my employees with wages as their sole compensation, will do (-) all of orU portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Cede: The
Contractors' State License Law does not apply to an owner of property whn, through employees' or personal offort, builds
or improves the property, provided chat the Improvements are not intended or offered for sale. if however, the building or
improvement is sold within ane year of completion, the Owner-Buklder will have the burden of proving that R was not built
or Improved forthe 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 Contractors' State License Law does not apply to an owner of property who
builds or improves thereon,and who contracts for the projectswilh a licensed Contractor pursuant tothe Cantmetors' Stale
Ucense Law.).
L) € am exempt from licensure under the Contractor's State License law for the following reasori(s):
By my signature below 1 acknowledge that, except lormy, personal resfdanee In which I must have resided for at least one
year poor to complofion of the improvements covered by this permiLi cannol legally sell a structure that I have built as an
owmr-builderlf ithas notbeen constructed in itsen[treiyby licensed contractors.I understand thata copy ofthe applicable
lavr, Section 7044 at the Business and Professions Gore is available upon requestwhen this application is submitted or at
the iollowing Web site: htWwww.leginto.se.gov/mlaw.html.
DATE: SIGN:—,-
LICENSED
IGN:—,_LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 {commencing with Section 7CDCI
of Division 3 of the Business and Professions Code, and my license is In full force and effect.
LICENSE�sCLASS: S--:, ,- 4 2- HC. NO.: _....,_,
DATE '1.-. t3r._ Iii CONTRA ..,... -:A E�
WORKER'S COMPENSATION DECLARATION
j IHERFBYAFFIRMUNDERPENALTYOFPERJURY ONE OFTHE FOiLOWIAGDECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
i
lion 3700 of the Labor Code, far the performance of the work for which this permit is issued.
f I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for
the pertormace of the war for which this permit Is Issued, My Workers Compensation Insurance Carrier and
Policy Nu sole:
j CARRIER /
i
POLICY NUMBER
1 (THIS SECTION NEED NOT BE CO I E ER IT i5 INEHDNpRED DDLLARS {S1B0) DR LESS)-
I codify that in the performance ofthe work for which this permit is issued, € shall not employ any person in any manner so as to
} become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to the Worker's
3
Compensation provisions of Suction 37D0 of the Labor Cntle, I shall forthwith comply with those pmvisians.
e
' DATE: APPLICANT:
7 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 cede, interest, and attorney's fees.
CONSTROCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work tar
which this permit is issued {Sen. 3097, Clv, C.).
LENDER'S NAME: ---
LENDER'S ADDRESS:
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
enter upon th ve-menti d property for inspection purposes.
PERMITTEE -N - (RI
0
E STfNATDREOFPERM1TiEE - UATE
f PPLICATION DATE: 7 0 Z WOW
ISSUE DATE: e PERMIT# PF'�
TYPE CONST. OCC GROUP:
ZONING SETBACKS
FRONT RW 0
REAR ❑
SIDE/SIDE STREET RW
SIDE ❑
PROPOSED USEVolilOIA
# DWFL. KNITS
# STORIES fE
CONSTRUCTION:
PLAN REVIEW:
DESCRIPTION SO. FT FACTOR PSF ADJ. AREA/VALUATION
ELLCTRIC:
SFR/ADD/RENT
PLUMBING:
Garage/Carport
co
M
Patio/Deck
LL
Pool/spa
zRe
-Roof
0
J
Commercial
m
_
BSAF:
Valuation:' _ Adj. Area: _
QUANTITY DESCRIPTION FEE
a
v
r --
w
w
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PAID BY: �! � �- m VALIDATION:
a
m
J
v
z
CONSTRUCTION:
PLAN REVIEW:
ELLCTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
°
SNIP:
ENERGY P/C:
_
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
_
BSAF:
TOTAL FEES
COMMENTS:
RECEIPT #
PAID BY: �! � �- m VALIDATION:
WHITE ---- Department Copy, YELLOW Finance Copy, PINK —Assessor Copy, GOLDENROD— File Copy, GREEN Applicant's Copy
CITY OF DIAMOND
INSPECTION
COMMENTS-