HomeMy WebLinkAboutPR16-2888CITY OF DIAMOND BAR F
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
" 21810 Copley Drive, Diamond Bar, CA 91765
n (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027
4, BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building(adiamonadbarca.gov
JOB SITE ADDRESS01611l
APN LOT TRACT
OWNE I ✓ �_ �-�- �
ADDRESS
CITY'_ ZIP'"C) - P TEL.
APPLICANTat TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/-
DESIGNER AJL� $f {
ADDRF,�S � _
CITY r ,-., ZIP T.7iL TEL. ;E�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of per)ury 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 items) [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 the permit to file a signed statement that he er she
is Icensed 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 Bcensure and the basis for
the alleged exemption. Aril latlor of Section 7031.5 by any applearl a permit subjects the appllcant to a civil penalty
of not more than five hundred dollars ($500).
(_) I, as owner of the property, army employees with wages as their sole compensation, will do (,) all of of 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 properly who, through employees' or personal effort, hullds
or improves the property, provided that the improvements are not intended or offered for sale. It however, the building or
improvement is sold within one year of completion, the Owner -Builder *111 have the burden of proving that it was not built
or improved forthe purpose of sale.).
(-)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 contractsforthe projectswith a licensed Contractor pursuanttothe Contractors' State
License Law.).
(J I am exempt from licensure under the Contractor's State License law forthe following reason(s):
Date: Sign:
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by this permit,l cannot legally sell a structure that I have built as an
owner -builder If it has flat been constructed in its entirely 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 at the following Web site: hlplwww,leginfo.ca.gov/calaw.hturl.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under pena€ty, 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.
1 !2
LICENSE CLASS � ejf ,`
EXP. DATE g CONTRACTOR:
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WORKER'S CO SATiO-� ECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -insure for Worker's Compensation, as provided by
! A,AySection 3700 of the Labor Code, forthe performance of the work forwhich this permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
e performance of the work for which this permit is Issued. My Worker's Compensation Insurance Carrier and
Policy Number : { f
CARRIER I. ^". .. d A,
POLICY NUMBER F,
(THIS SECTION NEED N T BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I oer11(y that Ili the performance of the work for which this permit is issued, I shall not employ any parsec in any mannerso a; to
become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to the Whirl
Compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with two provisions.
DATE; APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($I 0C.000), In addition to the cost of the compensation,
damages as pmvlded for in section 3709 o1 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 is issued (Sec- 3097, Civ, C.).
LENDER'S NAME:
LENDER'S ADDRESS:
i
I certify that I hava read this applicrEon and state that the above information is correct, I agree to comply with all city and
' county ordinances and slate laws relating to building construction, and hereby authorize representatives of this county to
entel above-mentioned property for inspection purposes.
.41/
PERMITTE"AME (PRINT) .meq
SIGNA Rl` RMITTEE : DATE
PRESS
FIRMLY
APPLICATION DATE: 1 -2 -ZZ 1/! P/C# PRIG-
� PERMIT# : P R, i 2
ISSUE DATE: 4
TYPE CONST. OCC GROUP:
9
890?
Scope of Work T dl a f�i°+j,
1
# DWFL. UNITS # STORIFS )! BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Carage/Carport
w
Patio/Deck
Lu
LL
Pool/Spa
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Re -Roof
n
Commercial
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Valuation: ¢`<->c%. Adj.Area:
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION: �gi
PIAN REVIEW: a T%
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ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE: .
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SMTP:
2, 2 -"` "Yg
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE`.
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BASF:
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PLOT PLAN: , 2-42.
ZONING CLEARANCE:
TOTAL FEES.58U00p,�
COMMENTS:
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PIC: PAID BY: ad ' Z VALIDATION:
RECEIPT # _- PAID BY: VALIDATION: f _
WHITE — Department Copy, YELLOW -- Finance Copy, PINK—Assessor Copy
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