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HomeMy WebLinkAboutPR17-10337CITY OF DIAMOND BAR i. { ' j DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Sar, CA 01765 PRESS (909) 839-7020 Fax-. (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY BUILDING PERMIT APPLICATION www.citvofdiamondbar.com building diamondbarca.�ov U., z 0 a UD J UD rr 0 UD a cc JOB SITE ADDRESS APN iOT- " TRACT I a� OWNER d ' ✓ k�V _..— ADDR S ' A fill __.3 eCITY IP EL APPLICANT TEL. • e-'-7, CONTRACTOR ( (� ADDRE 4 CITY y, " ZIP TEL. -4 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 reason(s) indicated below by the checkmark(s), I have placed next to the applicable item{s) [Section 7031L, 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 of the Contractor's State License Law (Chapter 9) Commencing with Section 7000 of Division 3 of the Business and Professions Code] drthat he or she is exempt from licensure and the basis for the alleged exemption. Ray violation of Section 7031.5 by any applicant for a permit subjects the applicantm a civil penalty of not more than five hundred dollars ($600). (-)1, as ownerof the property, or my employees with wages as their sole compensation, will do L) a1i of or (_) portions of the work, and the structure is rot intended or offered for said (Section 7044, Business and Professions Code: The 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 afcompletion, the Cwner-Builder will have the burden of proving that it was not built or improved for to 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 contractsforil projects with a licensed Contractor pursuanttothe Contractors' State License Law.). LJ 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 permlt,l cannot legally sell a structure that I have built as an owner -builder it it has not been constructed in its entirely by licensed contractors. I understand that a copy of 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: htlplwww.leginfo.ca.gdvlcalawhtml. 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 to Business and Professions Code, and my liGenjais in full force and effect. LICENSE CLASS: LIC. NO.: EXP. DATE: CONTAAC70R: WORKER'S ENSATION DECLARATION I HEAEBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I have and will malntalr a Certificate of Consant to Self -Insure for Worker's Compensation, as provided by A Section 37DU blithe Labor Code, forthe performance ofthe 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 performanc t work for which this per ' Is issued. My Worker's Compensation Insurance Carrier and Policy Number CARRIER 11yF, POLICY NUMBER (THIS SECTIDN NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS). I cergfythat in the performance of the work for which this permit is Issued, I shall not employ any person in any mannered alto become subject to the Worker's Compensation Laws of California, And agree that if I should become subject to the Worker's Compensation provisions otSeclion 3700 of the Labor Code, I shah 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 370E 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 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinance and state laws reI Ill g to building construction, and heraby authorize representatives of this county to enter upon ther e-menIda.dpro f inspect€o urposegs.� PERMITTEE NAME {PAIN SIGNA E OF PEA UATE . APPLICATION DATE: 7VW17 P/C# PR11- ! l ISSUE DATE 7 129Z1-7 PERMIT#: BRIT- 1033_� TYPE CONST. OCC GROUP: Scope of Work f # DWEL, UMTS # STORIES # BEDROOMS DESCRIPTION SQ. FT, FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport LW PaticXeck Lt1 LU ri Pool/Spa ZRe -Roof n Commercial m C CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: t�1• �R INSPECTION FEE: ISSUANCE: SMIP: ENERGY P/C: ENERGY PERMIT: RLTENTION FEE: PRE -ALT FEE: 2.00 BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: I �' PIC: �j PAID BY: VALIDATION: 6 RECEIPT 9 3 5 (0 1 PAID BY: 1/4233 Z VALIDATION: L C_ WHITE — Department Copy, YELLOW — Finance Copy, PINK Assessor Copy j, .I . slili COMMENTS: m 0O• Ll rt =3 O n � ro �* 4 7 � CL d W a ON O m O u Q C3 CD 0 n � 0 0 C) v m m a O r� m m PL NNm >� Ln 6 N V � W 5 4!i Tf! mm P Ln n o' aqq r� vt m -I S m 'r1 res to n rr O 7 Ln 9 Na CP Fi a F d CD w A do z � � n 16 JD a O 3 � 'a m 9 a o n O m b 0 'C C o T N N CL "' Nr,Z 0 O q C? a k � A � 1` �. mtoo m O .ye a M crm a 06 a. 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N �y o.. a� a Q C p CL m CL �- fU 111 T. m w 4 6 v m j m ° s o a U R7 ro b , N 7 m O n `n m n h c A o G n w N up ry �- ro m m O m ro :1 n' c o R 10 �" ro V ua w "11 b r.� m O e% 0 3 "O n Z h m b N m CERTIFICATE OF VERIFICATION CF3R-MCH-25-H Refrigerant Charge Verification (Page 4 of 4) Documentation Author's Declaration Statement 1. 1 certify that this Certificate of Verification documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Joe Salas Jovsvaa Company: Date Signed: JC HERS Services, LLC 2017-08-22 Address: CEA/ HERS Certification Identification (If applicable): 11390 Doverwood Drive RCN13122 City/State/Zip: Phone: Riverside CA 92505 951-217-0805 Responsible Person's Declaration statement I certify the following under penalty of perjury, under the laws of the State of California: 1. The Information provided on tNs Certificate of Verification is true and correct. 2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater), 3. The installed features, materials, components, manufactured devices, or system performance dfagnostic results that require HERS verification identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements specified on the Certificate of Compliance for the building approved by the enforcement agency. 4. The information reported on applicable sections ofthe Certificate.(s.) of Installation (CF2R) signed and submitted by the person(s) responsible for the construction or installatlon conforms to the requirements specified on the Certif€cate(s) of Compliance (CF1R) approved by the enforcement agency. 5. 1 will ensure that a registered copy of this Certificate of Verification shall be posted, or made available with the building permits) issued for the building, and made available to the enforcement agency for all applicable inspections. l understand that a reg€stered copy ofthis Certlficate of Verification is required to be included with the documentation the builder provides to the building owner at occupancy, Builder Or Installer information As Shown On The Certificate Of Installation Company Name (Installing Subcontractor, General Contractor, or Builder/Owner): All Pro Air Responsible Suilderor Installer Name: CSLB License: Barry Palmer 934601 NIERS Provider Data Registry Information Sample Group Number (if applicable): Dwelling Test Status in Sample Group (if applicable) N/A HERS Rater Information HERS Rater Company Name: JC HERS Services, LLC Responsible Rater Name: ResponsibEe Rater Signature: Joe Salas ibv-sazalk Resporsibie Rater Certification Numberw/this HERS Provider: Date Signed: RCN13122 2017-08-22 Digitally signed by CHEERSTM. This digital signature is provided in order to secure the content of this registered document, and in no way implies Registration Provider responsibility for the accuracy of the information. Registration Number: Registration Date/Time: 2017-08-22 19:31:04 HERS Provider: CHEERS 417-A020105972A-002-000- M 25000A- M 2 5A CA Building Energy Efficiency Standards Report Version: 2016.1.006 Report Generated; 2017-08-22 19:31:04 2016 Residential Compliance Schema Version: rev 10/16