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HomeMy WebLinkAboutPR16-1866F - ���`'� CITY OF DIAMOND BAR rl I i DEPARTMENT OF COMMUNITY 4t DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Bar, CA 91765 (909) 839-7020 Fax: (909) 861-3117 Building inspection Hotline (909) 839-7027 BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building(ajdiamondbarca.2ov JOB SITIE ADDRESS APN R € LOT TRACT _2-Z q377 OWNER V -y .0c) 6f ADDRESS CITYY T �y�a spa ZIP TEL. APPLICANT' e-0 TEL, 's 6 CONTRACTOR y ADDRESS d -y -� C, I [ d r� o $, /,VV E4 -`T- CITY ZIP TEL. ARCH/ENG/ DESIGNER- i ADDRESS 2,34dr i CITY di ZIP TEL. �" OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury chat I am exempt from the Contractor's State License Law for the reason(s) indicated below by the checkrnark(s), € have placed next to the applicable items) [Section 70315, Business and Professions Code: Any city of 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 theprovisionsof the Contractor's State License Law (Chapter 9) Commencing with Section 7060 of Division 3 of the Business and Professions Cade] or that he or she Is exempt from Ikon sure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicantfor a permit subjects the appllcantta a civil penalty of not mon: than five hundred dollars ($500). (-)1, as owner of the property, or my employees w€ih wages as their sole compensation, will do (-) all of or (_) 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 applyto an owner of property who, through employees' or personal effort, builds or improves the property, provided thatthe Improvements are not intended or offered for sale. If however, the building or Improvement is sold within one year of completion, the Owner-Builderwill have the burden of proving that it was nut built or improved for the purpose of sale.). (_)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 pursuanttothe Contractors' State License (r`,i am exempt from licensure under the Contractor's State License law for the following reasorl Date: Sign: By my signature below 1 acknowledge that, exceptfor my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this perai cannot legally sell a structure that I have built as an )caner builder if It has not been constructed in its entirety by licensed contractors, I understand that a copy of the applicable law, Section 7044 of the Business and professions Cade Is available upon request when this application is submitted or at the following Web site: httplwww.Ieginfo.ca.gov/calaw.hfml. 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.: _ E} EXP. DATE: 7/�A'7CONTRACTOR: ') -_"T a 7 WORKER'S COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAT]ONS: I have and will maintain a Certificate of Consent to SellInsolefor Worker's 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 work for which this permit is issued. My Worker's Compensation Insurance Carrier and Policy Number are: ,per CARRIER POLICY NUMBER (THiS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FDR ONE HUNDRED DOLLARS $100 OR LESq. I certi(ytrrat in the performance of the work for which this permitis issued, Wall not employ any person in any mannerso as to hemme subject to the Worker's Compensation Laws of California. And agree that If I should become subject to the Worker's Compensation provisions of Section 3700 of the Labor Code, I shall forthwith oomply wlth those provisions. DATE: APPLICANT: WARNING: Failure to secure Worker's Compensation coverage Is unlawful, and shall subject an employer to criminal pena€ties and civil fines up M one hundred thousand dollars ($100,000), 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 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: LENDER'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 ordinances and state laws rotating to building construetlon, and hereby authorize representatives ofthis county to enter upon the above-mentioned property for inspection purposes. PERMITT AME RINTJ GNATURE OF PERMITTEE DATE 1 Y PRESS FIRMLY APPLICATf N FIATS:elel �dtPIC# P°< ld ISSUE DAT AJ?14� PERMIT# TYPE CONST. OCC GROUP: Scope of Work C # DWEL. UNITS # STORIES # BEDROOMS I N SQ. FT. FACTOR PSF D ` I Garage/Carport ADJ. AREA/VALUATION `% -- toat€ ck w it LL 00 Re -Roof © Commercial m Valuation: C Adj. Area: QUANTITY DESCRIPTION FEE r w w Z -m nuoulak vi5�, J n. �rl�d v z z U 7F CONSTRUCTION: h d PLAN REVIEW: ELECTRIC: PLUMBING: s . MECHANICAL: r,.,... INSPECTION FEE: ISSUANCE: SI ENERGY PIG: ;�`�.� • �, ENERGY PERMIT: RETENTION FEE: PRE -ALT FEE: -, Cas — IllOVA BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES tii` v COMMENTS: P/C: J a � PAID BY: � VALIDATION: RECEIPT # PAID BY: VALIDATION: WHITE Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy COMMENTS: