HomeMy WebLinkAboutPR17-17755CITY OF DIAMOND BAR
DEPARTMENT 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
JOB SITE ADDRESS 230103 A+iQh Cil ld Vail
APN LOT TRACT
OWNER i aIm G
ADDRESS
CITY PbMV!/1d ZIP -11-10 TEL
APPLICANTI I TEL. '{l4'�-i9 ZSRG
CONTRACTOR All -A mer(i is n +I e- pe Iulrnbi nom_.
ADDRESS�f # ��
CITY TAI 11,I Dtl1 ZIP TEL. _1%-2:1a "� 9J(-
ARCH/ENG/DESIGNER
ADDRESS
CITY 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, after, 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 pursuanttothe 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 licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any apphcarnt for a permit subjects the applicant to a civil penalty
of not more Than five hundred dollars (5500),
U f, as owner of the property, or my employees with wages as their sole compensation, will do U all of or (_} 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 property who, through employees' cr personal effort, builds
or Improves the property. provided that the improvements are not intended or offered for Eels. It 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,).
(_) 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 projects with alicensed Contractor pursuanttothe Contractors' State
License Law.J.
O I am exempt from Ilcensure under the Coohactor's State License law forthe following reason(s):
By my signature below I acknowledge that, exceptfor my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by fills permit,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 cf the applicable
law, Section 7044 of the Business and Professions Cade is available upon request when this application is submitted or at
the following Web site: httplwwwfeglnfo.ca.gov/calawhtmi
DATE: SIGN:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7900)
of Civislcn 3 of the Business and Professions Code, and my license is in full farce and effect.
LICENSE CLASS: LIC, NO.: SGII 53'8
CATE: CONTRACTOR: Al AMe4.CM k DIPC A- LHm
WORKER'S COMPENSATION DECLARATION
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
Section 3700 of fire 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 of the Labor Code, for
the performance ofthe work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number raare:
' y^
CARRIER 4a:61 .i_.�,,"1—_j['3p 1�w+ G�✓ar't�l.
POLICY NUMBER ]FLA 66C ll -DD
{PHIS SECTION NEED NOT BE COMPLETED IF THE PERI IS FOR ONE HUNDRED DOLLARS ($100) OR LESS}.
I certify that In the performance ofthe workforwhich this permit is issued, I shall not employ any person in any manner sc as to
become subject to the Worker's Compensation Laws of California, And agree that If I should become subset to the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: 10117-1 APPLICANT: A Awe ti' t CPA. - iiii 0 um
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 cast of fee compensation,
damages as provided for in section 3706 of 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 cerSfy 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 above-mentioned property for inspection purposes.
PERMITTEE PREM]
SIGNAT RMITTEE DATE
PRESS
-:_... FIRMLY
APPLICATION DATE: 117— Vi
ISSUE DATE: I�
TYPE CONST.
T P/C#
PERI P P, 1 7 �
OCC GROUP:
ZONING SETBACKS
FRONT
REAR
SID EiSIDE.
SIDE/SIDE STREET
SIDE
RW ❑
0—
RW ❑
❑
PROPOSED USE
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF ADJ. AREA/UALUATION
SFR/ADD/REM
Garage/Carport
(0
Lu
Patio/Dock
LL
Pool/Spa
ZRe
-Roof
0
J
Commercial
DO
Valuation:
Adj. Area:
QUANTITY
DESCRIPTION FEE
M-
w
w
cn
z
m
14 cvm
ii
a
'
m
a
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:,
I�
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
33
SMIP:
ENERGY P/C:
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
1_
BSAF:
TOTAL FEES
COMMENTS:
3Z 82-
C?
RECEIPT# 300-1 PAID BY: ITZq VALIDATION:....__ -
WHITE— Department Copy, YELLOW Pinanco Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
CITY OF
DIAMOND
INSPECTION