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Home My WebLink AboutPR17-20298CITY 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 i FIRMLY BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building0amondbarca.gov JOB SITE ADDRESS S DDS G APN LOT TRACT OWNER W4V 49 ADDRESS Jill AA&14 Gil OD CITvWwlo+-Im AAn ZIPI/74-5 TEL a — d APPLICANT rl TEL e� j� Z. CONTRACTOR d« r_4E Li CA L_5040eef ADDRESS I_A".6. _, e0 -i CITY aft Alice ZIP g aft TEL. ley ��7 Z Z_ ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I herehy affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reasons) Indicated below by the checkmark(s), 4 have placed next to the applicable item{s) [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 permit to file a signed statement that he at 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 basis for theaile dexemption. Any vlolationofSection 7031.5byany applicant tar apermit subjects the applicanttoacivil penalty of not t Ore than five hundred dollars ($500). Ui,a, owner of the property, or myemployees with wages astheir sole compensation,will do(-) all oforUportions of the ork, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Con ars' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the properly, 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 for the purpose of sale.). U I, as owner ofthe 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 forthe projects with a licensed Contractor pursuant to the Contractors' State License Law.). O I am exempt from licensure under the Contractor's State License law forthe following reasorl 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 prior to cor ie6an of the improvements covered by this perm l cannot iegallysell a structure that I have built as an owner -builder if it has not been constructed In Its enttrety 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 yr at the following Web site: httptwvm.leginto,ca.gov/ca€aw.himi. 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. LICENSE CLASS: LIC. NO.: _ O D 7 0-57 EXP. DATE: CONTRACTOR: di to->rili LL&rnt/li.S-FIW- FS 10W j WORKER'S COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING OECLAAAT€ONS: 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 ofthe 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: ,i CARTER _1J4 ef 0J1J9 Qi o !® L1W_f!;_r POLICY NUMBER -Y-7-144i V Z' 317 - (THIS SECTION NEED NOT RE CDMPLETED IF THE FERMITIS FOR ONE HONORED DOLLARS 5100 On LESS). j I cedifythat in the performance of the work for which this permit is issued, I shall nat emplay any person in any manner so m to c become subject to the Worker's Compensation Laws of California. Arid agree that if i should become subject to the Worker's ComRensaIt p v Bions of Section 3700 a r Code I I fo comply Wlh those provisions. DATE APPLICANT:_ _ WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal 7 penalties and civil fines up to one hundred thousand dollars ($100,ODOJ, in addition to the cost of the compensation, 5 damages as provided form section 3708 of the labor code, Interest, and attorney's fees. CONSTRUCTION LENDING AGENCY u 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, Civ. C.), LENDER'S NAME: LENDER'S ADDRESS: Ll I certKy that I have read this application and slate that the above lnformation is correct I agree to comply with all city and a county ordinances and state laws relating to building construction, and hareby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. J S �Av 0 Y"i Igt n PER NAME PRI n s E SIGNATUFFE OF PFRMITT DATE'7 L7 APPLICATION DATE: 10 ISSUE DATE: TYPE CONST. n P/C# PERMIT# P9n_X&94T OCC GROUP: Scope of Work 1-00 At ]p $ tsK.r/1C£ (Oeik_"O 4W0__ # DWEL. UNITS # STORIES # BEDROOMS_ DESCRIPTION SQ. FF. FACTOR PSF ADJ. AREANALUATION SFR/ADD/REM Garage/Carport L6') Patio/Deck W u- Pool/Spa ZRe -Roof d Commercial D CQ Valuaiian: Adj. Area: QUANTITY DESCRIPTION FEE J v CE U w w CD z m a z U CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: SMTP: ENERGY PIC: ENERGY PEHMIT: RETENTION FEE: PRE -ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE: TOTALFEES COMMENTS: PIC: P RECEIPT #i, B - ° PAID BY: VALIDATION: VALIDATION: WHITE —Department Copy, YELLOW Finance Copy, PINK— Assessor Copy COMMENTS: