HomeMy WebLinkAbout12-505CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
DIVINE Br1W
21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION
JOBSITE �,5 ;
ADDRESS .`
APN LOT TRACT
OWNER K ikir� ^lPe� i� ff
ADDRESS
CITY ZIP TEL.
APPLICANT —� TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCWENG!
DESIGNER 7 �'
ADDRESS
CITY ZIP jj TEL. 14 141
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT t AM EXEMPT FROM THE CONTRACTORS LA
CElNSE LAW FOR THE FOLLOWING REASON ($E0. 7031.E BUSINES$AND PROFESSIONS OODE:ANYCITY OR
COUNTY WHICH REQUIRESAPERMITTOCOMBTRUC3 ALTER, IMPROVE, DEMOLISH, OR REPAIRANYSTRUG
TUBE, PRIOR TO TTS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 7O FILE SIGNED
STATEMENT THAT HE OR SHE 1S LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 7000)OF DIVISION 3OF 1(HF BU$IH£SS AND PRO-
FESSIONSCOOE)ORTHAT HE ORSHE IS EXEMPTTHEREFROMANDTHE BASIS FORTHEALLEGED EXEMP-
TION. ANY.VIO ATION OF SECTION 7031.5 BY A14YAPPUCANT FORA PERMIT SUBJECTS 7HE APPLICANT TO
ACIVILPENALTY OF NOT MORE THAN EWE HUNDRED DOLLARS (rsoO).):
131, ASOWNER OFTHE PROPERTY, OR MY WPLOYEE$ WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". RUSE
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, ANO WHO DOES SUCH WORKHIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIOTO THATSUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER, THEBUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
T1ON. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSEOF SALE).
0 I,ASOWNEROF THE PROPERTY. AM EXCLUSIVELYCONTRACT)NB WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS ANO PROFESSIONS CODE: THE CONTRACTORS LI-
CFNSE LAW DOES NOTAPPLY TORN OWNER OFA PROPERTYWHD BUILDS OR IMPROVES THEREON, ANO
WHO CONTRACTS FOR SUCH PROJECTS WUNAMWRAC7oR(SILICENSED PURSUANTTOTHE OONTRAC-
TORS LICENSE LAW.).
15IAM EXEMPT UNDERSEC. B. 3 P.C. FOR THIS REASON
DATE �� ._c3 ""- I ..�. OMER 51 63I
LICENSED CONTRACTORS DECLARATION
t HEREBY AFFIRM UNDER PENALTYOF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
R (COMMENCINO WITH SECTION 70001OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COOS, AND
MY LICENSE IS IN FULL FORCEANO EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OFPERJURY ONEOFTHE FOLLOWING DECLARATIONS:
l HAVE AND WELL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 370E OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,
I14AVEAND WILLMAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED RY SECTION
37000FTHE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICHTH1S PERMAIS.
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE:
CARRIER
POUCYNU)ABER
(THISSLL'J"NLBDNOTFIEM PIETEDOFTHEPEFM3S KRONE W,1DREDOOUMS(sI00)OHUUs%.
I CERTIFYTHAT IN THE PERFORMANCE OFTHE WORN FOR WHICHTHIS PERMIT is ISSUED. i
SHALL NOT EMPLOYANY PERSON INANY MANNER SOAP, TO BECOME SUBJECT TO THE
WORXERT WI)IFENSATION LAWS OF CALIFORNIA. ANDAGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PRovis N$ OF SECTION 3700 OFTHE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SE
SUBJEC7 AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100.ODD), IN ADDITION TO THE COST OF COMPENSATION.14AMAGES AS PROVIDED FOR IN
SECTION 370B OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
€ HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANC THE WORK FOR WHICH THIS PEHM.IT$S ISSUED (SEC.30o7, CIV.0.).
LENDER'SNAME_ff�y `.
LENDER'SADDRESS _ �.1 �- ��
I CERTIFY THAT$ HAVE READ THIS APPUCATKIN AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY oRDINANcrsAND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBYAUTHORIM REPRESENTATIVES OF THIS COUNTY TQ ENTER UPON THE
ABOV - ENTIONEO PROPERTY MWION PURPOSES,
PERMITTEE AME OR r`
BIGNATUR F. EAM�T3E ' UNIT
PRESS
FIRMLY
APPLICATION PERMIT % g) P/C
DATE p i �.� G�
NUMBER/�'
ISSUE �� TYPE OCC
DATE CONST. Wad,l GROUP
ZONING SETBACKS
FRONT RW ❑
REAR p
SIDElSIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL, NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTIO
SQ. FT.
FACTOR PSF
ADJ. AREAIVALUATION
SFRIADDIREM
1 ,,. ,v
07
Garage/Carport
loll
Patlo/DBek
u
PQOUSpa
Z
Re -Root
0
Commercial
5
ca
Va€Dallcm ADJ.AREA
QUANTITY
DESCRIPTION
FEE
U
H
UJ
ii
Z
CL
R
Q
U
z
a
U
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE +
SM€P
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE: I �
TOTAL FEES -�I
COMMENTS
RECPT. NO. AID BY VALIDATION
0
WHITE —Department Copy, YELLOW—RnaHce Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
CITY OF MAMOND BAR
INSPECTION RECORD