HomeMy WebLinkAboutPR17-2590a
G
L
F
JOB SITE ADDRESS
APN LOT TRACT
OWNER i a,, i� ��
ADDRESS � A:C
CITY ZIP TEL.
APPLICANT NN< .0 _ TEL. -2 ,_j
CONTRACTOR
ADDRESS
CITYZIP 1 TEL. n -i
ARCH/ENG!
DESIGNER
ADDRESS
CITY 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(s)
I(tdicated 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 applicantfer 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 basis for
the alleged exemption. Any violation of Section 7031.5 by any appfcantfor a permitsuhjectsthe applicantto a civil penalty
of not more than five hundred dollars ($500).
U I, as owner of the property, army employees with wages as their sale compensation, will do CJ all of or Q portions
of the work, and the structure 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 employses' or personal effort, builds
or improves the property, 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 1, 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 contractsforthe projects with a licensed Contractor pursuantto the Contractors' State
License Law.).
U I am exempt from licensure under the Contractor's State License law forthe following reason(s):
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 completion of the Improvements covered by this permif,l cannot legally sell a structure that I have built as an
owner builder If It has not been constricted 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
submitted or at the following Web site: httplwww.leginio,ca.govlcalaw.htni
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7DOO)
of Division 3 ofihe Business and Professions Code, and my license is in full force and effect.
LICENSE CLASS: LIC. NO.:
EXP. CATS: y to " CONTRACTOR; VA • L t e -V -
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWiNC DECLARATIONS:
have and will maintain a Cert€Sicato of Consent to Self Insure for Workers Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the 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 workfor which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number an:
CARRIER,%`"
POLICY NUMBER __an 2-
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $190 OR LESS).
I cergtythat in the performance of the workforwhich this permit is issued, I shall not employ any person in any mannerso as to
become subject to the Worker's Compensation Laws of Califwnia And agree that if I should become suhjectto the Worker's
Compensation provisions of Section 370D of the Labor Cade, 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 dines up to one hundred thousand dollars (Sl 00,000), In addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
i 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 (Serf, 3(1 Civ. C).
LENDER'S NAME: C -
LENDER'S ADDRESS:
i
I certify that I have read this application and state thatthe above information is correct.I 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 upogn, the above-mentioned property for inspection purposes.
PIPJuIE
(111 T)
r v?
7 _ -
SIGNATURE OF PERMITTEE DATE
r
APPLICATION DATE: = P/C#
ISSUE DATE: PERMIT# :P9J7 — 267
TYPE CONST. oI OCC GROUP:
Scope of Work P € i� � �-o
# DWEL. UNITS # STORIES
�_ �-- ;tl_y o' _
_ # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF
CITY OF DIAMOND BAR
w�
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
Garage/Carport
21810 Copley Drive, Diamond Bar, CA 91765
-
PRESS
Pool/Spa
(909) 839-7020 Fag: (909) 861-3117 Building Inspection Botline (909) 839-7027
C9
FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
Commercial
a
G
L
F
JOB SITE ADDRESS
APN LOT TRACT
OWNER i a,, i� ��
ADDRESS � A:C
CITY ZIP TEL.
APPLICANT NN< .0 _ TEL. -2 ,_j
CONTRACTOR
ADDRESS
CITYZIP 1 TEL. n -i
ARCH/ENG!
DESIGNER
ADDRESS
CITY 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(s)
I(tdicated 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 applicantfer 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 basis for
the alleged exemption. Any violation of Section 7031.5 by any appfcantfor a permitsuhjectsthe applicantto a civil penalty
of not more than five hundred dollars ($500).
U I, as owner of the property, army employees with wages as their sale compensation, will do CJ all of or Q portions
of the work, and the structure 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 employses' or personal effort, builds
or improves the property, 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 1, 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 contractsforthe projects with a licensed Contractor pursuantto the Contractors' State
License Law.).
U I am exempt from licensure under the Contractor's State License law forthe following reason(s):
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 completion of the Improvements covered by this permif,l cannot legally sell a structure that I have built as an
owner builder If It has not been constricted 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
submitted or at the following Web site: httplwww.leginio,ca.govlcalaw.htni
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7DOO)
of Division 3 ofihe Business and Professions Code, and my license is in full force and effect.
LICENSE CLASS: LIC. NO.:
EXP. CATS: y to " CONTRACTOR; VA • L t e -V -
WORKER'S COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWiNC DECLARATIONS:
have and will maintain a Cert€Sicato of Consent to Self Insure for Workers Compensation, as provided by
Section 3700 of the Labor Code, for the performance of the 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 workfor which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number an:
CARRIER,%`"
POLICY NUMBER __an 2-
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $190 OR LESS).
I cergtythat in the performance of the workforwhich this permit is issued, I shall not employ any person in any mannerso as to
become subject to the Worker's Compensation Laws of Califwnia And agree that if I should become suhjectto the Worker's
Compensation provisions of Section 370D of the Labor Cade, 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 dines up to one hundred thousand dollars (Sl 00,000), In addition to the cost of the compensation,
damages as provided for in section 3708 of the labor code, interest, and attorney's fees.
CONSTRUCTION LENDING AGENCY
i 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 (Serf, 3(1 Civ. C).
LENDER'S NAME: C -
LENDER'S ADDRESS:
i
I certify that I have read this application and state thatthe above information is correct.I 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 upogn, the above-mentioned property for inspection purposes.
PIPJuIE
(111 T)
r v?
7 _ -
SIGNATURE OF PERMITTEE DATE
r
APPLICATION DATE: = P/C#
ISSUE DATE: PERMIT# :P9J7 — 267
TYPE CONST. oI OCC GROUP:
Scope of Work P € i� � �-o
# DWEL. UNITS # STORIES
�_ �-- ;tl_y o' _
_ # BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck
-
W
IL
Pool/Spa
C9
Re-Roof
o
Commercial
m
Valuation.NOW&Adj.
Area:
QUANTITY DESCRIPTION
FEE
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CONSTRUCTION: �y®�
PLAN REVIEW:
ELECTRIC:
PLUMBING:
--_ �2-
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
�� L
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL. FEES
COMMENTS:
3
P/C: _ PAID BY: VALIDATION: @®�
RECEIPT tf _ 35034 PAID BY: VALIDATION:(',_.,
WHITE — Department Copy, YELLOW Fioa9se Cooy, PINI Assessor Ccpy
■ � � .. war ',�'
COMMENTS:
