HomeMy WebLinkAbout26807.pdfCITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21825 Copley Drive, Diamond Bar, CA 91765
909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS _ L 3% p+"`
S
1 " S 4' 7
APN LOT TRACT
OWNER _OZdS i_ ( T C1 NYtA-L I e
ADDRESS i7 k ( SGK,, a i I7Gt
CITY C-64-" ZIP (oTEL.
APPLICANT TEL. 323
CONTRACTOR
ADDRESS
CITY w ZIP —IV—kJVTEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC-
TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER Y (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (11500).):
L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE.
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
I, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7014, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC.
TORS LICENSE LAW.).
1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
e (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS e-10 LIC. NO. 15 1
DATE y- tai CONTRACTOR_
WORKERS' COMPENSATION DECLAATI N
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
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 WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER S / '41"tL 6 "'d
POLICY NUMBER ,y ?tea 095:) d
THIS SECTION NEED NOT BE OOMPLETED OF THE PERMIT IS FOR CNE HUNDRED DOU}AS ($100) OR LES4
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 BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE OVISKJNS.
DATE: ) APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATI CO ERAGE IS UNLAWFUL, ANDSHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (11100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST AND ATTORNEYS 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. 3087, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
PRESS
FIRMLY
APPLICATION
DATE
PERMIT P/C
NUMBER it
ISSUE G //TYPE
66 OCC
DATE t CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR
SIDE/SIDE STREET RW
SIDE
PROPOSED USE AcIC J G/O
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTIONSO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
U)
Garage/Carport
WPatio/Deck
LL Pool/spa
Z Re -Roof
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
U
UWLUW
zZ
O]
a
QU
Q2UW
CONSTRUCTION
PLAN REVIEW
ELECTRIC r
PLUMBING
MECHANICAL Z
INSPECTION FEE
ISSUANCE CO
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: I. DD
PRE -ALT FEE:
TOTAL FEES ob
COMMENTS
RECPT NO. PAID BY VALIDATION
VVHI I E-uep8rtment UOpY, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—Elle Copy, GREEN—Applicant's Copy
CITY OF DIAMOND RAR
INSPECTION RECORD
oaap c 400a as oaprca oa ooaa oaaac0.
SET BACK FLOOR JOIST
FTGS/FORMS/STEEL FHA REOMTS
ELECTRIC GROUND UNDER FLOOR DUCT
GROUND PLUMBING UNDER FLOOR CONDUIT
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING 8 FT. BOND BEAM
FRAMING/VENTILATION--- FINAL BOND BEAM
ROOF COVER PRE -GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST.
FINAL HEATING 4"t
FIRE DEPT. FINAL
HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBING ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE
a