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Home My WebLink AboutPR17-0333r— rr LU CD 0 0 LU cin J a rr 0 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@diamondbarea.gov JOB SITE ADDRESS APN LOT TRACT OWNER F v e 1 't"=. 3$ <'' rk ice_"', ADDRESS ¢ tl € CITY 4f'y €plj, ZIP jL APPLICANT TEL. --y CONTRACTOR•' a 0 ADDRESS CITYz Ii ZIP SB TEL. ARCHIENG! DESIGNER ADDRESS CITY 71P TEL OWNER -RUR DEH DECLARATION I hereby affirm under penally of perjury that I am exempt from the Contractor's State License Law for the reason(s) indicated below by the checkmark(s), I have placed next to the applicable cam(s) tSection 7831.5, 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 statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter9) Commencing with Section 7080 of Division 3 of the Business and Professions Code] or that he or she is exempt from Ilcensure and the basis for the alleged exemption. Any violation of Section 7031,5 by any appiicant for a permit subjects the applicant to a clvil penalty of not more than five hundred dollars ($500). (_)1, as owner of the property, ermy employees with wages as their sole compensation, will do O all of or O portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professlans Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal efforl, 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 one year of completion, the Owner -Builder will have the burden of proving that it was not built or improved forthe purpose of sale.). (-) 1, as owner of the property, am exclusively contracting with licensed Contractors to constructthe 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 pursuantto the Contractors' State License Law.). O I am exempt from licensure underthe Contractor's State License law forlhe following reasen(s): Date: Sign: By my signature below I acknowledge that, exceptfor my personal residence iR which I must have resided for at least one year prior to completion ofthe. improvements covered by Ynis permil,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: httplwww.leginfo.ca.govlca€aw.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 my license is In full farce and effect. r� 7;-1 rTi:x LICENSE CLASS: LIC. NO.: ) EXP. DATE: CONTRACTOR:' i`� -'. fir:_ _C ' i 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 ofthe 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 Number are:. P- CARRIER.fp«. . POLICY NUMBER {PHIS SECTION NEED NOT BE COMPLETED IF THF PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS). I certifythat in the performance ofthe workfor which this permit is Issued, I shall not employ any person in any manner so Este become subjectto the Worker's Compensation Laws of California. And agree that it I should become subject to the Worker's Compensation provisions of Section 3700 of lha Labor Code, I shall forthwith comply with two 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 ($500,000}, in addition to the cost of the compensation, damages as provided for in section 370B of the labor code, interest, and attorney's fees. CONSTRUCTION LENDING AGENCY t 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 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 pppn the above-mentloned property for inspection purposes. i'f rfa'...rRd y/1 ✓'T F,J y jJ 4:• PEAMIEE NAIA. (PRINT) SIGNAtU EOFPERM17EE DATE APPLICATION DATE: �'� C TA ISSUE DATE: ��€� PERMIT#: TYPE CONST. P/C# �p __ t' gym'® 3-3 OCC GROUP: Scope of Work ig If DWEL. UNITS It STORIES r re1P,£ e.? F # BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport 21 PatiolDeck ua L- Pool/Spa ZRe -Roof Commercial Cf] Valuation: Adj. Area: QUANTITY DESCRIPTION FEE v w w c� m J a. CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: _ l SMI P: ENERGY PIC: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: . P/C: PAID BY: VALIDATION:----,,v— ALIDATION:RECEIPTN 223no PAID BY: VALIDATION: RECEIPT 4 WHITE — Department Copy, YELLOW — Flnance Copy, PINK —Assessor Copy COMMENTS: