HomeMy WebLinkAboutPR17-10099CL
CL
JOB SITE ADDRESSjl� 5 V�- WWAr Ct V
nn
Al V LOT TRACT _
OWNER M OLVA h I
ADDRESS Ok1
CITY k pp a/IrZIPiI� STEL.
APPLICANT O
CONTRACTOR I 04LL(
ADDRESS S DIFF
CITYZIPnJ 1414 TEL. 9-5- V%29-2
AR /ENG/
DESI I
ADDR SS
CITY 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)
€ndicated below by the checkmark(s), I have placed next to the applicable itern(s) [Section 7031.5, Business and
Prolesstons Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior 10 its issuance, also requires the applicant for the permit to rite a signed statementthat 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] or that he or she is exempt from licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
(_) I, 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' 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 Due year of completion, the OwnerBuilderwill 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 a licensed Contractor pursuantte the Contractors' State
License Law,),
U 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,I 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 of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or atthe following Web site: http/www.loginfo,ua.gov/calaw.html-
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 Code, and
pandm'y license is in full force and effect.
LICENSE CLAS � LIC. NO.:1 A ... q �&l S
ExE. DATE;— CONTRACTOR: 5 1A 1i A+WJA&4n_-L
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE Or 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 the 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 of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy No -I r are: p- �i
CARRIER u r T L T 2�.
POLICY NUMBER
-- M__ - , A Me �� I
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNCHED DOLLARS $100 OR LESS).
I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to
became 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, € 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 ($100,000), in addition to the cost of fie compensation,
damages as provided for in section 3708 ofthe labor code, interest, and attorney'sfees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury thatthere is a Construction Lending Agency for the performance of the work for
which this permit is Issued (Sec. 3097, Clv. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information is correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
enter upon the above-mentioned property for mspectlon purpose$.
PERMITTEE NAME (PRIN A a bill
SIGNATURE OF PFRMITTE DATE t Y�
APPLICATION DATE: - 1 ig PIC# P R11 - 10099
9
ISSUE DATE: 7�2f'ef l � PERMIT#: PRI-+- 110099
TYPE CONST. OCC GROUP:
CITY OF DIAMOND BAR
¢
b
DESCRIPTION SQ. FT. FACTOR I
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765
PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection hotline (909)
839-7027
FIRMLY
W
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com
building@diamondbarea.gov
JOB SITE ADDRESSjl� 5 V�- WWAr Ct V
nn
Al V LOT TRACT _
OWNER M OLVA h I
ADDRESS Ok1
CITY k pp a/IrZIPiI� STEL.
APPLICANT O
CONTRACTOR I 04LL(
ADDRESS S DIFF
CITYZIPnJ 1414 TEL. 9-5- V%29-2
AR /ENG/
DESI I
ADDR SS
CITY 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)
€ndicated below by the checkmark(s), I have placed next to the applicable itern(s) [Section 7031.5, Business and
Prolesstons Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior 10 its issuance, also requires the applicant for the permit to rite a signed statementthat 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] or that he or she is exempt from licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
(_) I, 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' 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 Due year of completion, the OwnerBuilderwill 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 a licensed Contractor pursuantte the Contractors' State
License Law,),
U 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,I 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 of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this application is
submitted or atthe following Web site: http/www.loginfo,ua.gov/calaw.html-
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 Code, and
pandm'y license is in full force and effect.
LICENSE CLAS � LIC. NO.:1 A ... q �&l S
ExE. DATE;— CONTRACTOR: 5 1A 1i A+WJA&4n_-L
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE Or 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 the 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 of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy No -I r are: p- �i
CARRIER u r T L T 2�.
POLICY NUMBER
-- M__ - , A Me �� I
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNCHED DOLLARS $100 OR LESS).
I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to
became 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, € 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 ($100,000), in addition to the cost of fie compensation,
damages as provided for in section 3708 ofthe labor code, interest, and attorney'sfees.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury thatthere is a Construction Lending Agency for the performance of the work for
which this permit is Issued (Sec. 3097, Clv. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information is correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
enter upon the above-mentioned property for mspectlon purpose$.
PERMITTEE NAME (PRIN A a bill
SIGNATURE OF PFRMITTE DATE t Y�
APPLICATION DATE: - 1 ig PIC# P R11 - 10099
9
ISSUE DATE: 7�2f'ef l � PERMIT#: PRI-+- 110099
TYPE CONST. OCC GROUP:
Scope of Work ID'Y
# DWEL. UNITS # STORIES
s
4 BEDROOMS
DESCRIPTION SQ. FT. FACTOR I
ADJ. AREA/VALUATION
SFRIADD/REM
Garage/Carport
W
Patio/Deck
W
LL
Pool/Spa
Re -Roof
Commercial
m
Valuation:
Adj. Area:
QUANTITY DESCRIPTION
FEE
U
w
1�
z
m
ii
J
4
U
Z
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECT{ON FEE:
ISSUANCE:
SMTP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
2_00
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
Lill +4
P/C: Q PAID BY; VALIDATION:
RECEIPT q 3PAID BY: ��� VALIDATION: i -L
WHITE —Department Copy, YELLOW —Finance Copy, PINK— Assessor Copy
COMMENTS: