HomeMy WebLinkAboutPR17-15709- CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 1 rtbPRESS
w (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESS 117 Vt flock DC
APN LOT TRACT
OWNER �Lk--Y—„ I ii,
ADDRESS cl�e6i r
CITY L7 a I" ZIP�1�(�.-15 TEL. _I&
APPLICANT TEL. 7T eia�� -I(,7i
CONTRACTOR „ 4k ,OA
ADDRESS�s�
CITY' ZIP C3� TEL.)�y
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-8111t'i 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 haveplacednext to The applicable ifem(s) [Section 7031.5, Business and
Professions Code: Arty 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 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] or that he or She IS exemptli licensure and the basis for
the alleged examptlmn. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of rot more than five hundred dollars ($5CO).
(,1, as owner of the property, crmy employees with wages as their sole compensation, will do U all of ort) 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 Tatthe improvements are not intended or offered for sale, If however, the building or
improvement is sold within one year of completion, to Owner -Builder will have the burden of proving that it was not built
or improved for the purpose of sale.),
L.} 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 contractsforthe projects with a licensed Contractor pursuantto the Contractors' State
License Law.).
(} I am exempt from licensure underihe Contractor's State License law forthe following reason(s)c
Date: Sign:
By my signature below 1 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 this permif,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 this application is
submitted or at the following Web site: http/www.loginto.ca.gov/calaw.htmi.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that t am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my licenseisin full farce and effect.
LICENSE "SS: � LIC. NO.: � -I I d
EXP. DATE: CONTRACTOR: PjV?� �, ki ,rid T,6C.,
WORKER'S COMPENSATION DECLARATION
I HERERYAFFIRM UNDER PENALTY OF PER,iDRY ONE OF THE FOLLOWING DECLARATIONS:
I provided by
and will maintain a Certificate of Censent to Self Insure for Worker's Compensation, as pby
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 ofthe Labor Code, for
the performance of the work for which this permit Is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER t WA 146 lJll; (-Z� l
POLICY NUMBER L
(THIS SECTION NEED NOT BECOMPLETED IFTHEPERMff IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that in the performance of the work for which this permit is issued, I shall notemployany person In any manner so as to
become subject to the Workers 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 these provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage Is unlawful, and shall subject an employer to criminal
penalties and civil tines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
i I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work for
which this permit is issued (Sec. 3097, Civ. C.),
LENUER'S NAME:
LENDER'S ADDRESS:
i
I certify that I have read this appllcation and state that the above information is correct. I agree to comply with all city and
county ordinances and state laws relating to building construction, and hereby authorize representatives of this county, to
{ enter upon the above-mentioned property for inspection purposes.
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PERMITTEE (PAIN
t
SIGNATU P "� DATE
APPLICAT€ON DATE: S P/C#
ISSUE DATE: i �`� PERMIT# : f i$ ®-7 1
TYPE CONST. OCC GROUP:
Scope of Work �u
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
Carage7Carport
Lo
Patio/Deck
Lu
LL
Pool/Spa
ZRe
-Roof
Commercial
ft]
Valuation: Adj. Area:
QUANTITY DESCRIPTION FEE
U
r
V
111
J
c�
m
q
i
a
U_
2
x
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE: 1
SMIP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE: 1 �.
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: PAID BY: VALIDATION:
RECEIPT # PAID BY: VALIDATION:
WH ITE Department Copy, YELLOW Finance Copy, PINK —Assessor Copy
CITY OF DIAMOND EAR
INSPECTION RECORD
COMMENTS;