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 JOB SITEADDRFSSy. d- APN k; "? f a i7 °" OT r� � TRACT OWNER d� ^ °. r , ADDRESS Clamu i as � zlP Ti APPLICANT TEL. CONTRACTOR ADDRESS_ CITY ZIP TEL. ARCH/ENG/ DESIGNERit - ADDRESS {: : t hyo -Ft 4 CITY ZIP i,-' TEL. 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 r # DWEL. UNITS #STORIES �_ #BEDROOMS— DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION SFR/AD REM Garage/Carport CO LU Pat€o/Deok w U- Pool/Spa ZRe -Roof Commercial D Co Valuation. ;u U F Adj, Area: QUANTITY F DESCRIPTION FEE S 1 U it v , w ca z J v a z U CONSTRUCTION: PLAN REVIEW: ELECTRIC: S i� PLUMBING: MECHANICAL: INSPECTION FEE; ISSUANCE: Si _ �� ®3 ENERGY P/C: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: fD' BASF: `® PLOT PLAN: ZCNING CLEARANCE: , TOTAL FEES COMMENTS: —7Sd • 1,T— 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: