HomeMy WebLinkAboutPR17-9362CITY OF DIAMOND BAR b& �� -6 a — 6 0Sl t dr (in k- L.zz 4 co
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
Y 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.cityofdiamondbarcom building@diamondbarca.gov
APPLICATION DATE: 2-zi-1-7 P/C# PRIG- -43lZ
ISSUE DATE: PERMIT#r??e_ -7 -=a 3ll
TYPE CONST, OCC GROUP:
55
Scope of Work YM Q
# DWEL. UNITS # STORIES
JOB SITE ADDRESS
APN ON' LOT ThACT
OWNER
ADDRE S
CITY ZIPEL.
TEL.
APPLICANT -
CONTRACTOR Ce a
ADDRESS iei_3 �A
CITY - ZIP EL. u
ARCH/ENG/
DESIGNER
ADDR S1A 014 A
CITY 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)
Indicated below by the checkmark(s), I have placed next to the applicable Item(s) (Section 7033.5, Business and
Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, priorto Its Issuance, also requires the applicant for the permit to file a signed statementthat he or she
Is f€tensed pursuant to the provisions of the Contractor's State License Law (Chapter B) Commencing with5ection
7000 of Division 3 of the Business and Professions Cadef orthat he or she Is exempt from licensure and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permlt subjects the appllcarrt to a civil penalty
of not more than five hundred dollars ($500).
U t, as owner ofthe property, or my employees with wages as thelrsole compensation, will do U aif of or U portions
of the work, and the structure Is not Intended or offered for sale (Section 7044, Business and Professlons Code: The
Contractors' State License Law does not apply to an owner of property who, through employees' er 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 bull
or improved for the purpasa of sale.}.
U I, as owner ofthe property, am exclusively contracting with licensed Contractors to constructths project (Section
7044, Business and Professions Code, The Contractors' State License Law does not apply to an owner of property who
builds or Improves theroon, and who contracts forthe projects with a licensed Contractor pursuant to the Contractors' State
License Law.).
C.) I am exempttrom Iloensure under the Contractor's State License law for the fallowing reason(s):
Date: Sign:
By my signature below I acknowledge that, except for my personal residence In which I most have resided for at least one
year prlorto Completion of the Improvements covered bythls permlt,l cannot legally sell a structure that I have built as an
owner -builder if It has net been constructed in hs 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,leginfo.co,govtcalaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (oemmenclog wlth Section 7000)
of Dlvlslon 3 of the Business and Cade, and my Ileense Is In full force and effect.
��Professions
LICENSE OU65: l -L" G.LIC. NO.:
EXP, DATE: C�CONTRACTOR:
JJ�, WORKER'S O MPENSATIDN DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to SeU-Insure for Worker's Compeneatlon, as provided by
Section $700 of the Labor Code, forthe performance of the worktorwhich We permk is Issued.
1 have and wlll maintain Worker's Compensation Insurance, as required by Sect€on 3700 ofthe Labor Code, for
the performance of the work for which this permit Is Issued, My Worker's Compensation Insurance Carrier and
Policy Num by e:
CARRIER
POLICY NU BER ! v C
j` THIS SECTION NEED NOT BE COMPLErED IFTHE PERMIT ES FOR ONE HUNDRED DOLLARS $100 OR LESS).
I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person In any manner so as to
became subject to the Worker's Compensation Laws of California. And agree that If i should het me -subject to the Worker's
Compen bon proovlslon�f Secl3700 of Code,E FfafVlwlth cSm y e provisions.
APPLICANT:—
_
pensatlan coyera a Is unlawful, and shall subect an employer to criminal
WARNING: Faliure to secure Worker's C )
penalties and clvll fines up to one hundred thousand dollars (1510C,000), In addition to the cost of the compensallon,
damages as provided for in section 3708 ofthe 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 workfor
which this permit Is Issued (Sec. 3097, Cly. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state thatthe above Information Is correct. I agree to comply with 0 city and
county ordinances and state laws relating to bulking constructlon, and hereby authorize representatives of this courrtyto
e :on the above-mentioned pro for Inspection purposes.
M=2 INT)
SIG
UAE DATE
APPLICATION DATE: 2-zi-1-7 P/C# PRIG- -43lZ
ISSUE DATE: PERMIT#r??e_ -7 -=a 3ll
TYPE CONST, OCC GROUP:
55
Scope of Work YM Q
# DWEL. UNITS # STORIES
# BEDROOMS
DESCRIPTION $Q. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
Ow
Patio/Deck
W
LL
Pool
zRe
-Roof
Commercial
m
ValuatPa
Adj. Area:
QUANTITY DESCRIPTION
FEE
a
U
�i
w
Ed
CM
a
m
n.
v
CONSTRUCTION:
PLAN REVIEW:
343. TA _
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
SMTP:
STP
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE -ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
55 J • S
P/C: PAID BY: CD 1u!5 Z4 VALIDATION:
RECEIPT# - PAID BY: VALIDATION:
L%
WHITE— Department Copy, YELLOW — Finance Copy, PINK—Assessor Copy