HomeMy WebLinkAboutPR17-14760CITY OF DIAMONID BAR
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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 bailding(a diamondbarca.gov
JOB SITE ADDRESS A i 7 A
APN LOT TRACT
OWNER
ADDRESS
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APPLICANT ;C)t �'�;CJ TEL.'? `
CONTRACTOR V'k a "�, )
ADDRESS Jcq F " r-- r"i l'
CITY l L. ZIP TE C
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DESIGNER
ADDRESS
CIN ZIP TEL.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reason(sj
indicated below by the checkmark(s), I have placed next to the applicable Items) [Section 7031.5, Business and
Professions Code: 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 permitto Rte a all statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7DDD 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. Anyviolation of Section 7033.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
U I, as owner otthe property, or my employees with wages as their sole compensation, will do U all of or U portions
of the work, and the strucfure 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 that the improvements are not intended or offered for sale. If however, the bullding or
improvement is sold within one year of completion, the Owner -Builder will have the burden of proving that it was not bulb
or improved for the purpose of sale.).
(-) 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 contracts for TO projects with a licensed Contractor pursuant to the Contractors' State
License Law.).
U 1 am exempt from licensors under the Contractor's State License law for the fallowing reasoni
Date; Sign:
By my signature below I acknowledge that, except for my personal residence In which I must have resided for at least one
year priorto completion of the improvements covered by this permit,l cannot legally sell a structure that i have cult as an
owner -builder if it has not been constructed In Its entirety by licensed contractors, 1 understand that a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request when this appllcatlon Is
submitted or at the following Web site: httplwww.leglnfo.ca.govfealaw,html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am €lcensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Cade, and my license is in full force and effect.
LICENSE CLASS: �y�' �. � 0 LIC. NO.:
EXP. DATE: c CONTRACTOR f i 'Z . i. A] , t 1
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 is lssuad.,
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:
CARRIER A'` ( i
POLICY NUMBER 6 CA $ ii� a $' _ k
(THIS SECTION NEED NOT RF COMPLETED IFTHE PERMIT IS FOR ONE HUNDRED DOLLARS $100 01
I certlfyihat in the performance of the workfor which ihls permit is issued, i shall not employ any person In any manner so asto
become subject T the Worker's Compensation Laws of California And agree that if I should become subject to the Worker's
Compensation provisions of Sechon 3700 of the Labor Code, I shall forthwith comply with those 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 {$100,000), In addition to the cost of Te compensation,
damages as provided for in section 3708 of the labor code, 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 the work for
which this permit Is issued (Sec. 3097, Clv. C.).
LENDER'S NAME:
LEN DER'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 ordinancss and state laws relating to building construction, and hereby authorize representatives of this county to
enter upon the above-mentioned prop gf y for inspection purposes
P E NAME (PRINT)
SIGNATURE OF PERMITTEE DATE �t
APPLICATION,DFITE: If,`
ISSUE DATE: 0 £ PERMIT#iLe'
TYPE CONST. OCC GROUP:
Scope of Work
# DWEL. UNITS It STORIES # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ, AREA/VALUATION
SFR/ADD/REM
Garage/Carport
LOU
Patio/Deck
Ld
U_
Pool/Spa
(D
Re -Roof
o
Commercial
Z)
m
Valuation: Adj. Area:
QUANTITY D SCRIPTION FEE
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2
U
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Cel
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m
J
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC: .
PLUMBING:
MECHANICAL:
INSPECTION FEE:
..
ISSUANCE:
SMTP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BAS F:
PLOT PLAN:
ZONING CLEARANCE:
TOTALFEES W Z
COMMENTS:
PAID BY: VALIDATION:
RECEIPT �'�",". _.k r^ .PAIDBY:H` �.if-,�+`VALIDATION: `
WHITE — Department Copy, YELLOW — Finance Copy, PINK—Assessor Copy
CITY OF DIAMOND
INSPECTION