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Home My WebLink AboutPR17-890 (14)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVLI.OPMENT SERVICES -- 21810 Copley Drive, Diamond Bar, CA 91765 PRESS (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY "bag- BUILDING PERMIT APPLICATION www.cityofdiamondbar.com buildiriLC&diamondbarca.Qov JOB SITE ADDRESS ��tg1�61Ss ct� APN LiiO//T TRACT OWNER GIS h _ ft Li O ti�L1 i 4 ADDRESS, q S o Lc a ICS n q Mci S S b4 CITY ® 14 dfl f) N •C ZIP E TEL. C[ CI 11—CS�g I1G 3 APPLICANT TEL. CONTRACTOR _. ADDRESS. CITY ZIP TEL. ARCH/ENG/ T DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt tram the Contractor's State License Law for the reason{s) Indicated below by the checkmark(s), I havo placed next to the applicable Item(s) [Section 7031.5, Business and Professions Code: Any city or county that requires a permit be construct, alter, improve, demolish, or repair, any structure, prior to its issuance, also requires the applicant for the permitto file a signed statement that he or she is licensed pursuantto the provisions of the Contractor's Stale License Law (Chapter 9) Commencing with Section 7000 of Division 3 of the Business and Professions Cartel 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). ,0rasowner pftheproperty, ormyemployees with wages asTheirsolecompensation, will doUallofor t,ortions 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 chat the improvements are flat intended or offered for sale. If however, the building or improvement is sold within one year of completion, the Owner -Bulkier will have the burden of preying 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 buikds or improves thereon, and who contractsfor the projects with allconsed Contractor pursuant be the Contractors' Slate License Law.). L) I am exempt tram Ilrensure under the Contractor's State License law forthe following reason(s): Data: Sign: By my.signaiure below € acknowledge that, except for my personal residence in which I must have resided total least one Year prior to completion attire Improvements covered by this permlt,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 of the applicable law, Section 7044 of the Business and Professions Code is available upon request when chis application is submitted or of the following Web site: htlplwww.leginfo.ca.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 UMsion 3 of the Business and Professions Code, and my license is in full force and effect. LICENSE CLASS: LIC. I EXP. UA7B CONTRACTOR: ''WORKER'S COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I have and will maintain a Certill of Consent to Solt -insure for Worker's Compensation, as provided by Section 3700 of the Labor Cede, for the performance of the work for which this permit Is issued. I havo 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 Poligy Number are: CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS). I certify that in tine performance of the work for which this permit Is issued, I shall not employ any person in any manner so a5 to become subject to the Worker's Compensation Laws of California. And agree that if I should become subject to Ina Worker's Compensation proysioes of Section 3700 cf the LaborCode, I shall forthwith comply with those provisions. DATE: APPLICANT: WARNING: Failure to secure -Worker's Compensation coverage is unlawful, and stIRII subject an employer to cdminal penalties and civil fovea up to one hundred thousand dollars ($100,000), in addih'en to the cast of the compensation, damages as provided for In section 3708 of the labor code, interest, and allcmey's fees. CONSTRUCTION LENDING AGENCY 1 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 app€icatiom and state that the above information is correct. I agree to comply with ail city and county ordinances and state laws relating to building coustruclion, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. VC, TI � Q 1 6-1 PERMITTE AME (NT} f j 1. � S t 2C1i SIGNATJR MITTEE . DATE 1 APPLICATION DATE: J 7 1-1201-7 P/C# T O 1 ISSUE DATE: PERMIT# : TYPE CONST, OCC GROUP: Scope of Work H&ffirnli POM o U , — Add 'S cmd -� 5y # DWEL. UNITS # STORIES # BEDROOMS DESCRIPTIONSQ. FT. FACTOR PSF ADJ. AREA/VALUATIONSFFI EM Garage/Carport C.0 PatfolDerk WLL Pool/Spa Z Re-Ftaot i Commercial m FEE U U J w WHITE Department Copy, YELLOW -- Finance Copy, PINK— Assessor Copy