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HomeMy WebLinkAboutPR17-2858Q CITY OF DIAMOND BAR DEPAR'T'MENT OF COMMUNITY & DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Bar, CA 91765 (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 BUILDING PERMIT APPLICATION www.cityofdjamondbar.coml bnilding@diamondbarca.gov JOB SITE ADDRESS tS L JD 4(tpAl s� APN LOT TRACT ' OWNERe4amAaadS �,�r✓ I ADDRESS C CITY. Its. ZIP9i}9I 7 APPLICANT TEL. E CONTRACTOR �R �C Ylt7etl E �}c ADDRE S _�L�Z CITY LJ PC ZIP�TEL, Ir '� ARCH/FN DESIGNER ADDRESS i CITY ZIP TEL. OWNER-BUILDFR DECLAAATION I hereby affirm under penalty of perjury 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 or she is licensed pursuantto the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section 7000 of Division 3 of the Business and Professions Code] orthat he or she is exempt from licensure and the basis for t the alleged oxempton. Any viDiat[on of Section 7031.5 by any applicantfora Pormitsubjects the applicant to a civil penalty Of not more than five hundred dollars ($500). U I, as owner of the property, or my employees with wages astheir sale compensation, will do O a0 of or (_) portions of the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professions Code: The i 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 completion, the Owner -Builder will have the burden of proving that it was not built or improved for the purpose of sale.). as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sectlen 7044, Business and Professions Code: The ContractorsState License Law does not apply to an owner of property who builds or improves thereon, and who contracts forthe projects with a licensed Contractor pursuant to the Contractors' State License Law,), O i am exempt from licensure underthe Contractor's State License law forthe following reasorl 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 priorto completion of the improvements covered by this permiLl cannot legally sell a structure that I revs 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 at the following Web site: http/www. Ieginfo.ca.gov/csaw.hlml, LICENSED CONTRACTOR'S DECLARATION I 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 Cade, and vmyylicense is In full force and effect, LICENSE CLASS: LIC. NO.: � � -c- 'T EXP. DATE: CrOR: WORKED' PENSATION DECLARATION I HEREBY AFFIRM UNDER PE JURY ONE OE THE FOLLOWING DECLARATIONS: have and will maintain a Certificate of Consent to Self Insure for Worker's Compensation, as provided by /Isi ection 3700 of the Labor Code, for the performance of the workfor which this permit Is issued. ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance ofthe work for which this permit is Issued. My Worker's Compensation Insurance Carrier and Poll Number CARRIER G POLICY NUMBER (11-115 SECTION NEED NOT DE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOH ARS $100 OR LESS). I GDOythat in the performance of the work for which this permit is issued, I shall not employ any person in any mannerso asto become subject to 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, 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 ofthe labor code, interest, and attorney's fees. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that then; 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 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 the ve-menticnedproperty for inspection purposes. Q.��� , �. io.dT PERMITTEE NAME (P SIGNATURE O RMITTEE DATE PRESS FIRMLY APPLICATION DAT ISSUE DATE: TYPE CONST. 1 OC PERMIT#: P/C# OCC GROUP: Scope of Work ' # DWEL. UNITS i 04 � # STORIES s! # BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFH/ADDf REM Garage/Carport m Patio/Deck LL Pool/Spa � Re -Roof © Commercial Valuation: t Adj. Area: QUANTITY DESCRIPTIO FEE J U cc U ru cndig z_ na. S SCat J _U 2 CONSTRUCTION: PLAN REVIEW; - P` ELECTRIC:£ u PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: SMIP: (y ENERGY PIC: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE; BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: r F r P/C: PAID BY: VALIDATION: HECE€PTf! PAIDRY: VALIDATION:,,,-_` WHITE— Department Copy, YELLOW — Finance Cepy, PINK —Assessor Copy COMMENTS: yea oz-ft-wfi Wa) F -I, I LU c w vo 'Jee puowt�!G - - I . It < m -1 Cl) any laEOnN PIOD OOOIZZ .1 z 98L16 V3 'purldl 01 Q AI-Aag T (jcjs'ja6uejF) 41 0 0 u -US a�W MSIA aluOlk ZfrZI i %014---�Gz) opluxulz LL 9 0 LL 0 to Cq LU CL 0 . .. . .. .... OD uj 0 CO) 06 05 C 'd 06 U -006 06 cL cL E CL m LU D 0 0 0 0 0 LLI C13 LL 0 z EL 06 06 .6 :j Z3 0 m :3 X Co co x 0 — � 0 Ir cc 7�6 CO iFU 4) 4) (1) 4) a) 0 RI co 5 °'zzzz z z 3: CIO Q ip 10(o &I am LLJ -Ir cq CL LU IL CIA -Easo 0 -a ED o (D 03 m T z a. CL cr- OD