HomeMy WebLinkAboutPR17-0239=.__^ CITY OF DIAMOND BAR
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
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diatnpndbarca.gov
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APPLICANT TEL.
CONTRACTOR
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DESIGNERit
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OWNER -BUILDER DECLARATION
I hereby afflrm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasons)
indicated below by the checkmarx(s), I have placed nest to the applicable items) [Section 7631.5, Business and
Professions Gode: 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 statementthat he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7666 of Division 3 of the Business and Professions Code) or that he or she is exempttrom 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 then five hundred dollars ($500).
U 1, as owner of the property, or my employees with wages as theirsole compensation, will do U all of orU portions
of the work, and the structure is not Intended or offered for sale (Settlor 7044, Business and Professions Code: The
Contractors' State License taw 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
mprovement is sold wifhin one year of completion, the Owner-Roilder will have the burden of proving that it was not built
or improved for the purpose of sale),
u I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
704d, Business and Professlors Code: The Contractors' State License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts fortheprojects win alicensed Contractor prnsuarr the Contractors' State
License Law.).
i I am exempttrom €ieeesure underthe Contractor's State License law forthe following reason(s):
Date: Sign:
By my signature below I acknowledge that, sxoepttar my personal residence in which I must have resided for at least one
year prforto completion of the improvements covered by this permit) cannot legally sell a structure that € 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 avai€able upon request when this application is
submitted or all following Web site: htVlwww.leginfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
I he y affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70DO)
of Division 3 of the Business and Professions Code, and my license Is In full force and effecl.
LICENSE CLASS: & HC. NO.: V 9 $�— J? 0 'en
F�fP. DATE: -C,,6 '. b -i CONTRACTOR: —� �E9
P d'. ' . X " i%s"
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 the Labor Code, for the performance of the work for which this permit to issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Cade, for
the performance ofthe work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
(NIS SECTION NEED NOT BE COMPLETED IFTHE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certifythatin the performance ofthework forwhich this permit is issued, I shall not employ any person in any menrerso as to
become 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 ofthe Labor Cade, I shelf forthwith comply with those provisions,
DATE: APPLICANT:
WARNING: Failure to secure Workers 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 cede, 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 no work for
which this permit is issued (Sec. 3097, GV C.).
LENDER'S NAME:
LENDER'S ADDRESS:
entity that I have read this application and state that the above information is correct. I agree to comply with all city and
only ordinances and state laws relating to building construction, and hereby authorize represenla Ives of this county to
enter upon the above-mentioned property for inspection purposes,
1
PERMRTEENAME (PRINT}
SIGNATURE OFPERMITTEE DATE
APPLICATION DATE: 2Z/ J
ISSUE DATE: (6 /iTPi 7 PERMIT#
TYPE CONST.
P/C# Ft ._ "
OCC GROUP:
Scope of Work �_ c, v1 -J y '� "� "Z n 10 "vi'_ s —10
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# DWEL. UNITS #STORIES �_ #BEDROOMS—
DESCRIPTION SQ. FT. FACTOR PSF
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
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PLUMBING:
MECHANICAL:
INSPECTION FEE;
ISSUANCE:
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ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
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BASF:
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PLOT PLAN:
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TOTAL FEES
COMMENTS:
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P/C: - - S PAID BY: VALIDATION:
RECEIPT # f PAID i3Y: VALIDATION: V—
WHITE — Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy
C-ITY OF DIAMOND :; ;
INSPECTION RECORD
COMMENTS: