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HomeMy WebLinkAbout23121.pdfCITYOFDIAMONDBAR DEPARTMENT OFCOMMUNITY & DEVELOPMENTSERVICES 21825CopleyDrive, DiamondBar, CA91765 909) 839-7020Fax (909) 861-3117BuildingInspectionHotline (909) 839-702 BUILDINGPERMITAPPLICATION JOBSITE ) /~ 1filetJ 1 i l ADDRESS' t i APOLOTTRACT INNER ADDRESS3 /rr' CITY, IYZPTEL-. APPLICANT -' 1TE - CONTRACTrt ADDSSn CITY4.1ZIPTEW101) / RCWENG/ DESIGNER ADDRESS CITYZIPTEL. OWNER-BUILDER DECLARATION IHEREBYAFFIRM UNDERPENALTYOFPERJURYTHATIAMEXEMPTFROMTHECONTRACTORS LI- CENSELAWFORTHEFOLLOWING REASON (SEC- 7031.5BUSINESSANDPROFESSIONSCODE: ANYCITYOR COUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER, IMPROVE, DEMOLISH, ORREPAIRANYSTRUC- TURE, PRIORTOITSISSUANCE. ALSOREQUIRESTHEAPPLICANT FORSUCHPERMITTOFILEASIGNED STATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROVISIONS OFTHECONTRACTORS U. CENSELAW (CHAPTER9 (COMMENCINGWITHSECTION7000) OFDIVISION3OFTHEBUSINESS ANDPRO- FESSIONSCODE) ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- TION. ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANT FORAPERMITSUBJECTSTHEAPPLICANTTO ACMLPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS ($505).): LASOWNEROFTHEPROPERTY. ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, WILLDOTHEWORKANDTHESTRUCTUREISNOTINTENDEDOROFFEREDFORSALE (SEC. 7044. BUSI- NESSANDPROFESSIONS CODE: THECONTRACTORSLICENSE LAWDOESNOTAPPLYTOANOWNEROF PROPERTYWHOBUILDSORIMPROVES THEREON, ANDWHODOESSUCHWORKHIMSELFORHERSELFOR THROUGHHISORHEROWNEMPLOYEES, PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR OFFEREDFORSALEIF. HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- TION. THEOWNER-BUILDERWILLHAVETHEBURDEN OFPROVINGTHATHEORSHEDIDNOTBUILDOR IMPROVEFORTHEPURPOSEOFSALE)- 0LASOWNEROFTHEPROPERTY, AMEXCLUSIVELY CONTRACTINGWITHLICENSEDCONTRACTORS TOCONSTRUCTTHEPROJECT (SEC. 70". BUSINESSANDPROFESSIONS CODETHECONTRACTORSLF CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON, AND WHOCONTRACTSFORSUCHPROJECTS WITHACONTRACTOR(S) LICENSEDPURSUANTTOTHECONTRAC- TORSLICENSELAW.) IAMEXEMPTUNDERSEC. B. & P.C. FORTHISREASON DATEOWNER LICENSEDCONTRACTORSDECLARATION IHEREBYAFFIRMUNDER PENALTYOFPERJURYTHATIAMLICENSEDUNDER PROVISIONSOFCHAPTER B (COMMENCINGWITHSECTION7000) OFDIVISION3OFTHEBUSINESSANDPROFESSIONS CODE, AND MYLICENSEISINFULL ANDEFFECT. FQR l/~ I3 LICENSECL,pS S LTC. NO. ff DATEI /L 'L'4CONTRACTOR I.!\[ ~'11*- ilO WORKERS' COMPENSATION DECLARATION IHEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' COMPENSATION, ASPROVIDEDBYSECTION37000FTHELABOR CODE, FORTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED. IHAVEANDWILLMAINTAINWORKERS' COMPENSATIONINSURANCE, ASREQUIREDBYSECTION 3700OFTHELABORCODE, FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED. MYWN) KE{RS' COMPENSATINSURANCECARRIERANDPOLICYNUMBERARE: 7 F1 CARRIER ~^! e Y~ POLICYNUMBER D(% 1V ? MSSECTIONNEEDNOTBECOAWLETEDOFT/EPERMITISFORONEHUNDREDDOLLARSK100)ORLESS} ICERTIFYTHATINTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED. I SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE WORKERS' COMPENSATION LAWSOFCALIFORNIA. ANDAGREETHATIFISHOULDBECOME SUBJECTTOTHEWORKERS' COMPENSATION PROVISIONSOFSECTION3700ELABOR CODE, ISHFORTHWITHCOMPLYWITHTHOSEPIIONS. CCC"S DATE PP T A LICAN WARNING: FAILURETOSECUREWORKERS' COMPENSATION COVERAGEISUNLAWFULANDSHALLBE SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND DOLLARS (5100,000), INADDITIONTOTHECOSTOFCOMPENSATION, DAMAGESASPROVIDEDFORIN SECTION3708OFTHELABORCODE. INTEREST. ANDATTORNEY'SFEES. CONSTRUCTION LENDINGAGENCY IHEREBYAFFIRMUNDER PENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDING AGENCY FORTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED (SEC. 3087, CIV. C.). LENDERSNAME LENDERSADDRESS CERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBULDING CONSTRUCTION. ANDHEREBYAUTHORIZEREPRESENTATIVES OFTHISCOUNTYTOENTERUPONTHE ABOVE-MENTIONEDPROPERTYFORINS ECTION PURPOSES. P TUNT) TTEE L EEDATE WHITE-Department Copy. YELLOW-FinanceCopy, PIN C APPLICATIQN ate ~~.5NPERMITUMBERa3) OI DATE10/ ISSUEC InsTYPE O Ia 0 DATE CONST. GROUP ZONINGSETBACKS FRONTRW REAR SIDE/SIDESTREETRWE) SIDEp PROPOSEDUSECC) & i1/7-d( 1 NO. DWEL. NO. NO. UNITSSTORIESBEDROOMS DESCRIPTIONSQ. FT.FACTORPSFADJ. AREANALUATION SFR/ADD/REM U)Garage/Carport WPatio/Deck LL Pool/Spa 0 ZRe-Roof CCommercial In ValuationADJ.AREA QUANTITYDESCRIPTIONFEE J 0 U w W Z 03 J Q z U W CONSTRUCTION PLANREVIEW ELECTRIC PLUMBING MECHANICAL INSPECTIONFEE ISSUANCECAD SMIP ENERGY P/C ENERGYPERMIT RETENTIONFEE: Op PRE-ALTFEE: tczc- Icy . ew TOTALFEES COMMENTS RECPT. NO. OPAIDBY1I1L 'J1VALIDATION.:' PRESS FIRMLY aTBACK E ELECTR/CGR~u| lGnOU§DeL27@~ SAABGFi,~t~~ TEI~' ~~' "~;-~ VVATE'~' `~ FRAt~~EN~` G TIC~' IG~~IC VVALL!V3t kJ:WG~ R~'~t~1P1. ~_. EV~EF~. L!t~C I'll°~`1~_l~. GASAIRTEST, 1~At~ ix"f~IAL FINALELECTRIC IFINALPLUMBING SEPTICTANKSIZE_ SEEPPO'/USIZE e~'~~Q~~~s~ATEINSPECTt~~`