HomeMy WebLinkAboutPR17-0054 (13)CITY OF DIAMOND BAR
DEcARTMENT 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
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OWNER
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APPLICANT 11j, TEL.
CONTRACTOR L-1.61. v i A- t.�'
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DESIGNER
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasons)
indicated helaw by the checkmark(s), I have placed next to the applicable item(s) iSecdon 7031.5, Business and
Professimu; 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 permit to file a signed statement that he or she
is licensed pursuantto 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 basis for
the a€! :ged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicantto a Civil penalty
of not more than five hundred dollars ($500).
C1 I, as owner of the property, or my employees with wages as their sole compensation, will do L) A of or (_) portions
of the work, and the structure is not intended or offered for safe (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 lntended 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 bunt
or improved for the purpose of sale.).
U I, as owner ofthe property, am exclusively contracting with licensed Contractors to construct the project (Section
(044, 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 pursuant to the Contractors' State
License Law.).
(_) I am exempt from licensure under the Contractor's State License law for the following reason(s):
Date, Sign:
By my signature below I acknowledge that, except formypersonal residence in which I must have resided for at least one
year prior to completion ofthe improvements covered by this parmit,l cannot legally sell a structure that I have built as an
owner -builder if It has not hoer 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
r submitted or at the following Web slte:hhplwww.leginto,ca.govlcalaw.himl.
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 force and effect.
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LICENSE Cl LIC. NO.:
] EYP. BATE: 3 4 --2 0 4tCONTRACTOR: ,a }
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j WORKER'S COMPENSATION DECLARATION 7-W b'
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: L.
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
eflon 3700 of the Labor Cade, for the performance of the work forwhlch 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 Workons Compensation Insurance Carrier and
Policy Number are:
CARRIER r�,) �_��`�` .v °s:ti Lt??jq in -.J _
i POLICY NUMBER
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(PRI3 SECTION NEEP NOT RE COMPLETED IFTHE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that in the performance of the workforwhich this permit is Issued, I Out not employ any person in any mannerso as to
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5 become subject to the Worker's Compensation Laws of Ga€l ia. And agree that if I should become subject to the Worl
jCompensation provisions of Section 3700 of Ore Labor Code, I shall forthwith comply with those..provisions.
DATE: APPLICANT:L2LV� (,A I� A�+rpt C
WARNING: Failure to secure Worker`s Compensation coverage is unlawful, and shall subject an employer to criminal
u penalties and civil fines up to one hundred thousand dollars ($100,OCC), in addition to the cost of the compensation,
j damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
E CONSTRUCTION LENDING AGENCY
u I hereby affirm under penalty of perjury that there is a Construction Lending Agency for the performance ofthe work for
which this permit is issued (Sec. 3097, Civ. C.).
5 LENDER'S NAME:
C LENDER'S ADDRESS:
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L I certify that I have read this appllcation and state that the above information is correct. I agree to comply with all city and
E county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to
z enter upon the above-mentioned property for inspection purposes.
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PERMITTEE NAM,(PRINT)
SIGNATURE PERMITTEE DATE
APPLICATION DATE: I ` P/C# IF`—T—
ISSUL DATE:_ `�1.. 4 PERMIT# : N a ' m t`.: >
TYPE CONST. OCC GROUP:
Scope of Work
I # DWEL. UNITS # STORIES 2- # BEDROOMS ..._
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DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck
Pool/Spa
Re -Roof
Commercial
Valuation: 'fi. Adj.Area:
CONSTRUCTION:
PLAN REVIEW: ®a
QUANTITY I DESCRIPTION FEE
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ENERGY P/C:
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BASF:
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CONSTRUCTION:
PLAN REVIEW: ®a
ELECTRIC:
PLUMBING:
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MECHANICAL:
INSPECTION FEE:
ISSUANCE:
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ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:f
PRE-ALT FEE:
BASF:
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PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: :, PAID BY: �6 s VALIDATION:
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RECEIPT#ILS PAID BY: VALIDATION:
WHITE— Department Copy, YELLOW -- Finance Copy, PINK —Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS:
Cabinet Installation Master
635 E. Whittier Blvd La Habra, CA 90631
Phone: (562) 691-9001/Fax: (562) 691-9088
License number: 989680
Wednesday, May 24, 2017
To City of Diamond bar:
would like to inform you that I would like to take my name off the following permits, or as your
representative described it to me on the phone call today (cancel the permits) , the homeowner have
denied us access work , we worry that she will be hiring another licensed or unlicensed person to
preform work under my permit, I don't want take responsibility for someone else's work.
This is the permits numbers:
PR16-1579
PR17-0054 For windows.
House address is at :
2520 Crooked Creek Dr
Diamond Bar Ca 91765
Sincerely
Salam Mahmoud
Contractor.