HomeMy WebLinkAboutPR16-2419CITY 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)N39-7027 FIRMLY
BUILDING PERMIT APPLICATION. www.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESS ®T
APN LOT TRACT
OWNER
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APPLICANT ��TEL.EzY S I ® V S
CONTRACTOR
ADDRESS
CITY ZIP � 1'3 L.�l —
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DESIGNER
ADDRESS
CITYtAS_-�ZIP - TEL.` 10
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)
indicated 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 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
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 appllcant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($5001
11,
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Cade: Tile
Contractors' 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 improvements are not Intended or offered for sale. If however, the building or
improvement is sold within one year of completion, the Owner-Bu€Ider will have the burden of proving that I was not built
or improved forthe purpose of sale,)
U I, 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 contracts forthe projacls with a licensed Contractor pursuant to the Contractors' State
License Law.).
am exempt from licensure underthe Contractur's State License law forthe following reason(s):
Date: Sign:
By my signature below I acknowledge that, except far my personal residence in which I must have resided for at least one
year priorto completion ofthe Improvements covered by this permit,l call legally sell a structure that I have hunt as an
owner -builder if it has not been constructed In Its ent€rety 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 attire folluwing Web site: http/www,leginfo.co.gov/calRw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm order penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7060)
of Division 3 of the Business and Professions Code, and my license is in full force and effect
r_ r" s ` r
LICENSE CL SS:� LIC. NO.:
DATE:CONTRAc7oR:
WORKER'S COMPENSATION DECLARATION -
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: .
I have and wil! maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 379D of the Labor Code, forthe performance of the work for win€er this permit Is issued.
I have and will maintain Worker's Compensation Insurance, as r u€red by Section 3706 of the Labor Code, for
the performance of the work for which this permit is issued. ' rker's Compensation Insurance Carrier and
Policy Number �
! CARRIER
POLICY NUMBER lid
i
"IS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS EOR ONE HUNDRED DOLLARS $106 OB LESS).
i
i Icerbfyihatintheperfonnanceoflhewprkfirwhichthispermitisissued,lshallnotemployanyperspninanymanne[soasYo
i become subject to the Worker's Compensation Laws of California. And agree chat if I should become subject to the Worker's
Compensation provisions of Seel 3700 nfthe Labor Code, I shall forthwith comply with [rose provisions.
r
DATE APPLICANT:
i WARNING: Failure to secure Worker's Compensation coverage 18 unlawful, and shall subject an employer to criminal
i penalties and civil fines up to one hundred thousand dollars (5160,000), in addition to the cost of the compensation,
damages as provided for in section 3768 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 (See. 3097, Civ. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
i
I certify that I have read this application and state tat the 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 upon the altge-mentioned properly for inspection purposes.
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PEBMITTE E (PRINT) t
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IGNATURE of PERMITTFE DATE
APPLICATION DATE:: )6 W PIC#
ISSUE DATE [ f Iii t— PERMIT# qPQ \l r
TYPE CONST OCC GROUP:
Scope of Work
# DWEL. UNITS # STORIES
# BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
Patio/Deck
r�i
Pool/Spa
C9
Re-Roof
Commercial
m
Valuation:
Adj. Area:
QUANTITY DESCRIPTION
FEE
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w
w 0
13
y
ra
0 -
CONSTRUCTION: CONSTRUCTION:
PIAN REVIEW:
.
ELECTRIC:
PLUMBING:
1 .ZL
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
_
SMIP:
ENERGY PIC:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE; a
BASF:
PLOT PLAN:
a�
ZONING CLEARANCE:
TOTAL FEES , ✓
COMMENTS:
1
PIC: PAID BY: VALIDATION:
RECEIPT O PAID BY: ' 1®k9M VALIDATION: Slim
WHITE — Department Copy, YELLOW Finance Copy, PINK --Assessor Copy
INSPECTION RECORD
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