HomeMy WebLinkAboutPR16-2837CITY OF DIAMOND BAR
l r 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
BUILDING PERMIT APPLICATION www.cityofdiamondbarcom building@diamondbarea.gov FIRMLY
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OWNER -BUILDER DECLARATION
I herehy affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the reason(s)
Indicated below by the chackmark(s), I have placed next to the applicable items) [Section 7031.5, Business and
Professions �ude: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicantfnr the permit to file a signed statement that he or she
is licensed pursuantto the provisions of the Contractor's State License Law (Chapter g) Commencing with Section
7000 of Division 3 of the Business and Professions Codel orthat he or she is exemptfrem licensare and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects fire applicant to a civil penalty
of not more than five hundred dollars (5500).
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do U all of or(-) portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code; The
Conlractors' 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 lmpmvemer€ts are not intended or offered for sale. If however, the building or
kriprovement is sold within one year of completion, the Owner Builder will have the burden of proving that it was not built
or improved far the purpose of sale.).
L) I, as ow5d 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 properly who
builds or imprgvus thereon, and who ccntractsfortha projects with a licensed Contractor pursuantto the Contractors' State
License Law)
(_) I am exemptirom Efcensure under the Contractor's State License law forthe following mason{s):
[late: Sign;
By my signature below I acknowledge that, exceptfor my personal residence In which I must have resided for at leastone
yearprior to completion of the lmprovements covered by this permit,I cannot legally sell a sfrneture 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, I Section 7044 of the Business and Professions Code Is available upon request when this application Is
Snhmifted or of the following Web site; hUplwwvwteginfo.m.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby afflim under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing wfth Section 7000)
of Division 3 o1 the Business and Professions Code, and my Ilcense is in full force and effect.
LICENSE CLASS: LIC. NO.: l
FXP. DATE- CONTRACTOR: _ ..
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA>-TY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's CompeasatRan, as provided by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have andvaill maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance ofthe worktor which this permit Is issued. My Worker's Compensation Insurance Carrier and
Policy Number are;
CARRIER 6%t I
POLICY NUMBER tv Cre, 15-, —_1 Y
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that in the pedormanca of the work for whtah this permit is issued, I shall not employ any person In any manner so as to
become subject to the Worker's Compensation Laws of California. And agree that If I should become subject 10 the Worker s
Compensation provisions of Section 3700 of the Labor Code, I shall fcrTv lth comply with those provisions.
DATE: _APPLICANT:
WAHNiNG: 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 ($10Q000), in sell lion to the cost of the compensation,
damages as provided for in section 3700 attire labor code, interest, and attorney's fees,
CONSTRUCTIDN LENDING AGENCY
I bunchy affirm under penalty of perjury that there is a Construction Lending Agency for the performance of the work for
which this perm. It is issued (Sec. 3097, Civ. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state thatthe above information Is correct f 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 upon the above-mentionad properly for inspection purposes.
PERMITTEE NAME (PRINT)
SIGNATURE OFPERMITTEE DATE
APPLICATION DATE: W .5 -iii P/C#
ISSUE DATE: PERMIT#
TYPE CONST. - OCC GROUP:
Scope of Work l2Ct[43
S' ? c's u F ;' t '
# DWEL. UNITS # STORIES
g
# BEDROOMS ,
DESCRIPTION SQ, Ff. FACTOR PSF
ADJ. AREA/VALUATION
SFRIADOIREhA
Garage/Carport
w
Patio/Deck
Li
Pool/Spa
ZHe
-Roof
Commercial
m
Yafuafion: C.
Adj. Area:
QUANTITY DESCRIPTION
FEE
/M ill
a
r
v
u,
M
M
a
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2
U
CONSTRUCTION: q�
PLAN REVIEW: as,1
ELECTRIC;
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
PIC: 3s1AS_,_,_ PAID BY: VALIDATION:_ Lam_
RECEIPT # PAID BY: -_� VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK—Assessor Copy