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HomeMy WebLinkAboutPR17-5482CITY OF DEPARTMENT T OF COMMUNITY & j 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.cityofdtamondbar.com uildi g@diamondbarea.gov LU JOB SITE ADDRESS 1 z CD All LOTTRACT LLIOWNER 1 1• s ZI ADDRESS o� I1 SS I �n i a CITY LA-) LIRA&L-A.- —ZIP Ti CD APPLICANT TEL. o CONTRACTOR m ADDRESS �`� o CITY ZIPTEL. ARCH/ENG/ z DESIGNER O z ADDRESS a CITY ZIP TEL. 22 OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State Ucense Law for the reason(s) w indicated below by the checkmadc(s}, I have placed next to the applicable items) lSechon 7031.5, Business and z Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any LU 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 (Chapter 9) commencing with Section 7000 of Division 3 of the Business and Professions Code] or that he or she is exempt from licensure and the hosts for rn the allegedexempton.AnyviolationofSection7031.5byanyapplicanttorapannitsub}ectstheapplicanHoacYlpenalty rr of not more than five hundred dollars ($500). 0 ® (-)1, as owner ofthe property, or my employees with wages as weir sole compensation, will do U all of or L) portions z of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The w Contractors' State License Law does not apply to Sr, owner of property who, through employees' or personal effort, builds or improves the property, provided that the [mprovements are not Intended or offered for sale. If however, the building or CD improvement is sold within ore yearof completion, the Owner -Builder will have the burden of proving that it was not built or improved for the purpose of sale.). z L} I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Gode: The Contractors' State License Law does not apply to an owner of property who Y builds orimprovesthereon, and who contmi;lsfortheprojectswithalicensed Contractor pursuanttotheContractors'State License Law.). CD (J I am exempt from licensure under the Contractor's State License law for the following reascal z Date: Sign: CD By my signature below I acknowledge that, except for my personal residence In which I must have resided for at least one year prior to completion of the improvements covered bythls pera l cannot legally sell a structure that € have built as an Q 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 o submitted or atthe following Web slte: httplwww.leginfo.ca.govlcalaw.html. l v LICENSED CONTRACTOR'S DECLARATION mI 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 force and effect coco r LICENSE CLASS: LIC. NO,: zz EXP. DATE CONTRACTOR: d 0 f% o WORKER'S COMPENSATION DEC RATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: o I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by 4 Section 3700 of the Labor Cade, forthe performance of the work for which this permit is Issued. } _ I have and will malntain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for athe performance of the workfor which thla permit I issued, My. Worker's Compensation Insurance Carrier and Policy Number are: o w CARRIER z CID POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED IFTHE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS), E3 I oedify that in the performance of the work for which this permit is issued, I shall not employ any person in any marnerso asto m 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 of the Labor Code, I shall forthwith comply with those provisions. M DATE: APPLICANT. WARNING: Failure to secure Worker's Compensation coverage Is unlawful, and shall subject an employer to criminal wpenalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cast of the compensation, C=D- damages as provided for In sechon 3706 otthe labor code, interest, and attorney's fees. Cz CONSTRUCTION LENDING AGENCY LU 1 hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work for = whlob this permit is issued (Sec. 3097, Clv. C.). r LENDER'S NAME rr LENDER'S AUDRE$S: LU � f certify that I have read this application and state that the ahove information is correct. I agree to comply with all all and z county ordinances an state laws relating to building construction, and hereby authorize representatives of this county to n enieruponthea v entionedprope fpr inspedionpurposes. m � ill PE Ml ME {PRINT) SQ �d = SIGNA URE OF ERMITTEE DATE H APPLICATION DATE: al 1 -7 P/C# ISSUE DATE: PERMIT# : Q I I Z TYPE CONST. OCC GROUP: Scope of Work # DWEL. UNITS # STORIES # BEDROOMS w w LL ('3 z O toto DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport Patio/Deck Pool/Spa Re -Roos Commercial Vafuatian: r Adj. Area: CONSTRUCTION: -PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: 1 SMIP: ENERGY P/C: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE�� DESCRIPTION FEE TOTAL FEESp�—p COMMENTS: OQUANTITY PIC: PAID Ell VALIDATION: RECEIPT# PAID BY: i'O VALIDATION: V� ' CD m d a z a V CONSTRUCTION: -PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: 1 SMIP: ENERGY P/C: ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE�� TOTAL FEESp�—p COMMENTS: PIC: PAID Ell VALIDATION: RECEIPT# PAID BY: i'O VALIDATION: V� ' WHITE — Department Copy. YELLOW — Finance Copy, PINK — Assessor Copy TMTTTE �o. COMMENTS: Address: —.1 Legal owner's Name (if different from above): Phone Number: Address: Diamond Bar Municipal Code Section 22.44.040 states an application fee must accompany this application. The application fee is either a flat fee or a. deposit plus .payment of the City's processing costs computed on an -hourly basis. If it is a deposit, the applicant shall pay any processing costs that exceed the amount of the deposit prior to issuance of the permit, if processing costs are less than the deposit, a refund will be paid. Type of Review Requested (Please Check All Applicable Boxes) ❑ Administrative Review ❑ General Plan Amendment ❑ Subdivision ❑ Annexation ❑ Minor Conditional Use Permit ❑ Tree Permit ❑ Comprehensive Sign Program ❑ Minor Variance © Variance ❑ Conditionai Use Permit ❑ Planned Unit Development J Zone Change ❑ Development Review ❑ Plot Plan X Zoning Clearance ❑ Development Agreement ❑ Preliminary Review ❑ Other: ❑ Development Code Amendment ❑ Specific Plan Amendment Project Description Detailed Description of Pjropo�sye1d4 Project (Attar>ch Additional Sheets if Neecyess{}ary),� y s " 4 / E ^J k f✓' \ "'_ 6,.$)F1J Y [ iY C.✓�. Owner Certification I certify that i am presently the legal owner of the above-described property. Further, I acknowledge the filing of this application and certify that all of the above information is true and corrot. (If the undersigned is different from the legal property owner, a letter of authorizatio)nust accompany the A Date:f .2 i Print L.211 Name and Title: AQplcant Print Name and TJ-tle: CommDev/Apps/UniformAppllUniform Application—Updated�r z 2 Planning Division Application Form A�%IFfIS�� Part 2 X989 Community Development Department —21810 Copley Drive —Diamond Bar, CA 91785 — (909) 839-7030 — www, DiamondBarCA.gov GENERAL REQUIREMENTS {Print or Type); Project Location:l Staff Use Only r � ��S s I� Case No. Applicant: !<�& /_)j 612 Z Concurrent Case No. Contact Person: Address: /8 PhoneAu }m \b/Qf�r: 2/1 -4/3(? -7 q �/4 / // 2 �1 �/7 Fax: �/•] /� �/f} E -Mail Address: V / f /—`71 J ) ( //1 /_ / �% ^5 %O I ./ n, 1-7 /'A /]✓Y)n:Y A__ Additional Contact Person: (Please specify name, company, title) Address: Phone Number: I Legal Property owner. Address: Phone Number: F Architect: Address: Phone Number: F, Engineer: Address: Phone Number: Fs Landscape Architect: Address: Phone dumber: Fa -1 " -v« PPua IulHI V13uunnarm,vpplrcatl0n—Updated 311412x12 E -Mail Address: E -Mail Address: E -Mail Address: E -Mail Address: E -Mail Address: Page 2 of 2