HomeMy WebLinkAbout16034 - 21865 E COPLEY DRCITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190 ,. '�
74�(909) 860-3195 Fax (909) 861-3117 (�1 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE
ADDRESS Zk S G Co \
APN LOT TRACT
OWNER
ADDRESS 2
CITY P S10 fEL_�—����2
APPLICANT ' TEL.14g: '-
CONTRACTOR
ADDRESS
CITY ZIP TEL
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DESIGNER
ADDRESS
CITY ZIP -g.2122t2TEL4I
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7051.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REGUIRESA PERMIT TO CONSTRILUC7,ALTER, BAPROVE,DEMOLISI. OR REPAIRANY STRUO
TORE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER a (COMMENCING WITH SECTION 7000) OF DIVISION G 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 7001.6 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DCIURS(1SW).):
O LAS 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 ISEC. 70". BUSL
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY VHO 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 POR SALE IF,HOWEVE0.THE BUILDING OR IMPROVEMENT IS SOLD VRTHNONE YEAR OF COUPLE.
TXON. THE OWNER -BLANDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
MPPOVE FOR THE PURPOSE OF SALE).
❑ L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 704/, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI•
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WIND CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC•
TORS LICENSE LAW).
O 1 AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
(COMMENCING (COMMENCG WITH SEC7ION 7000) OF DIVISION a OF THE BUSINESS AND PROFESSONS CODE, AND
MY LICENSE IS N FULL FORCE MID EFFECT. _
LICENSE CUSS LIC. NO. / �� �P�
DATE k* L U CONTRACTOR 7�1w\
WORKERS' COMPENSATION DECLARATION
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 WOFIK FOR WHICH THIS PERMIT IS ISSUED.
_ I HAVE AND W LL MAINTAON WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
57000E THE LABOR OWE. FOR THE PERFORMANCE OF THE WORK. FOR WHICH THIS PERMIT IS
ISSUED. MY Vp1a(EAS' ODMPENS(^A�TIDN�_ INSURANCE
`CARRIER AND POLICY NUMBER ARE:
CARRJER «� S.�'�J, m yyv�7LJ'� _
POLICY NUMBER GEL tD 10 219
(nas SECTION NEED NOT BE DOW=OF THE PERMIT IS FOR ONE HUNDRED DOLLARS (SIW)ORLM%
I CERTIFY THAT LATHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 5 MD SECO
SUBJECT TO THE WORKERS' COMPENSATION PROVIS OF SECTION Al IF THE I
CODE. I SHALL FORTHWITH COM H SF\PRC.
DATE: I • 21-1 (1� APPLIGABI
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
RS (E100,0M), IN ADDITION TO THE COST OF COMPENSATION. DAMA7ES AS PROVIDED FOR IN
SECTION 1706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
1 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, 3097. CN. C.).
i
LENDERS NAME
LENDERSADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOYE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CCUNTY TO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
L
1
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710ITUREOPW44ALIT—TLEDATE
APPLICATION I
1 G� PERMIT % P/C
DATE
NUMBER ✓ N
ISSUE
TYPE OCC
DATE
CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
—ci C
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
In
Garage/Carport
WPatio/Deck
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IL
Poot/Spa
ZRe
-Root
0
Commercial
m
Valuation ADSAREA
QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION ) '
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES ID.
COMMENTS
I Vt.,;I.
RECPT NO. _ PAID BY VALIDATION
WHITE —Department Copy, YELLOW —Finance Copy. PINK —Assessor Copy, GOLDENROD —File Copy. GREEN —Applicant's Copy
CITY OF DIAMOND BAR
-INSPECTION'RECORD
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-SET BACK i ; ; 1 ;
FLOOR JOIST.----,,
FTGS/FORMS/STEEL
FHA REQMTS
ELECTRIC GROUND
UNDER FLOOR DUCT
:GROUND PLUMBING
UNDER FLOOR CONDUIT
SLAB GRADE
FIREPLACE FOUNDATION
(TEMP POWER
FIREPL ,'dt BOPJD BEAM.
'WATER SERVICE
MID HT. BOND BEAM '
ROOFSHEATHING i
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_'
-8 FT. BOND BEAM),
iFRAMING.NENTILIATION.
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FINAL BOND BEAPA
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ROOF COVER
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PRE -GRADING
IROUGH HEATING
BENC}ilNG . I %W
ROUGH ELECTRIC.
ROUGH GRADING
'ROUGH PLUMBING
FINISH GRADING
'SHOWERTFUB TEST
POOUFLECTRIC'..
;EXT.-LATH/SIDING :"
POOL FENCING'
'WALL INSULATION
POOL FINAL
CEILING INSULATION
OFF SITE IMPS.
DRYWALL NAILING
DEDICATIONS
-SEVJER
FINAL ENG. .
.SEPTIC TANK
LANDSCAPEARRIG.
'SEEP PITJL.L.
ON SITE IMPS.
GAS AIR TEST
FINAL ZONING
FINAL CONST.
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17
FIRE DEPT. FINAL
FINAL HEATING .._ ..
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HEALTH DEPT. FINAL
,JAL ELECTRIC
I
DEV. FEES PAID
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1_4_!;,i .L PLUMBING
ENERGY
I COMMENTS =
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'SEPTIC TANK SIZE
,SEEP PIT/U SIZE
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