HomeMy WebLinkAboutPR16-252810ND BAR
='s ! a'
ILIM
CITY 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 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov
JOB SITE ADDRESSI TI
Z..
APN ��T LOT TRACT
OWNER 1
ADDRESS
CITY '. a ZIP ! "� TEL -16,21-6)
APPLICANT c': TEL t
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/El
DESIGNER Si_V B'' �il
ADDRESS C
CITY - ZIP EL-
OWNFR-BUILDER DECLARATION
I hereby affirm under penalty of perjury Shat I am exempt from the Contractor's We License P sons}
indicated below by the chockmark(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 applicant for the permitto 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
7600 of Division 3 of the Business and Professions Code] orthat he orshe is exsmptfrom licensure and the basis for
the alleged exemption. Anyviolation of Section 7031.5 by any applicant fora permit subjects the applicantto a civil penalty
of not more Ihan five, hundred dollars ($500).
U 1, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or G) 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 properly, provided thatthe Improvements are not intended or offered for sale. If however, the building or
improvement is sold within one year of completion, the OwnerBuilderwill have the burden of proving that It was not hulk
or improved for the purpose of sale.).
U 1, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sectlon
7944, 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 Law.).
(, I am exemptirom licensure underthe Contractor's State License law forthe following reason(s):
Date: Sign:
By my signature below I acknowledge that, exceptfor my personal residence in which I must have resided for at leastone
year prior to completion of the improvements covered by this permit,l cannot legally sell a structure 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, Section 7044 of to Business and Professions Cade Is available upon request when this application is
submitted or atthe following Web site: httpfwww.leginfo.ca.govfcalaw,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)
(if Division 3 ofthe Business and/Professions Code, and my license is in full force and effect.
LICENSE CLASS: LIC. NO �T
EXP. DATE: 21 /? fy CONTRACTOR: L, i E" .,
WORKER'S COMPENSATION DECLARATION a
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 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 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 -
CARRIER
?
POLICY NUMBER
{fl -IIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certrythat in the performance ofthe work for which 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 herons subject to the Worker's
i Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply wghthose provisions.
DATE: APPLICANT:
s
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 ($100,099), in addition to the cost of the compensation,
g damages as provided for in section 3700 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, Civ, C.).
LENDER'S NAME:
LENDER'S ADDRESS:
i
I certify that I have read this application and state Tatthe 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
S enter upon the ahove-mon6Gned property for inspection purposes.
`,
i 41
PERMITTEE NAME (PRINT] e r
'- ^. (
SIGNATURE OF PERMITTEE % DATE
APPLICATION DATI 12 W/ PIC#
ISSUE DATE: I° PERMIT# : N —
TYPE CONST. OCC GROUP:
Scope of Work Op-piazo
# DW EL. UNITS # STORIES # BEDROOMS
P
DESCRIPTION SQ. FT- FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD E
Garage/Carport
Lu
Patio/Deck
W
LL
Pool/ Spa
(D
Re -Roof
_3
Commercial
03
Valuation.') Ad}. Area:
QUANTITY DESCRIPTION FEE
f.0
..p,•P
z
M
z
2
CONSTRUCTION: C®
PLAN REVIEW:r
Laic
ELECTRIC: JBV
PLUMBING: i03, 10
MECHANICAL: mm .
INSPECTION FEE:
ISSUANCE: kip
Si 1
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
P/C: PAID BY: VALIDATION:
RECEIPT # 6m VI79 PAID BYY VALIDATION: LC
WHITE Department Copy, YELLOW —Finance Copy, PINK—Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS: