HomeMy WebLinkAboutPR16-2920CITY OF DIAMOND BAR /
• -' �i N � I � r ' DEPARTMENT OF COMMUNITY &DEVELOPMENT SERVICES
' 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.cityofdiamondbar.com building@diamondbarca.gov
O L O o ut ` (A
JOB SITE ADDRESS
.S u` C V 1 l .
APN LOT TRACT
OWNER A L', ce-
ADDRESS t~ r
CITY IROA IP TEL.762.6 0
APPLICANT TEL.
CONTRACTOR G .1. (-+"�
ADDRESS S - ft/ u C V-e
CITY Ar— dot/:(A ZIP TEL. R
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP 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 7031.5, Business and
Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair, any
structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9) Commencing with Section
7000 of Division 3 of the Business and Professions Code] or that 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 permit subjects the applicant to a civil penalty
of not more than five hundred dollars 1$500).
U I, as owner of the property, or my employees with wages as their sole compensation, will do U all of or U portions
of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who, through employees' or 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 built
or improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State
License Law.).
U I am exempt from licensure under the Contractor's State License law for the following reason(s):
Date: Sign:
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by this permit,l cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its 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 fallowing Web site: http/www.leginfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force and effect.
e,
� 3 �.
LICENSE CLASS: LIC. NO.: O U n
EXP.DATE: CONTRACTOR: V IT `h
WORKER'S COMPENSATION DECLARATION
II HE7FFinm UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I have and will maintain a Certificate of Consent to Self -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My Worker's Compensation Insurance Carrier and
Policy Number are:
CARRIER vu �~
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS 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
become subject to the Worker's Compensation Laws of Califmmia. And agree that if I should become subject to the Worker's
Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE: APPLICANT:
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of the compensation,
damages as provided for in section 3708 of the 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 work for
which this permit is issued (Sec. 3097, Civ. C.).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have read this application and state that the above information is correct. I 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 NAMEPRINT) +
SIGN- EOF ERMITTEE DATE V
APPLICATION DATE: t"-/ Sod I t
ISSUE DATE: 1ZI a�I � PERMIT#:
TYPE CONST.
nP/C#
P(z Ito
OCC GROUP:
Scope of Work `l -
# DWEL. UNITS # STORIES
# BEDROOMS
DESCRIPTION
SQ. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
GarageJCarport
w
Patio/Deck
w
u-
Pool/Spa
ZRe
-Roof
Commercial
rn
Valuation:
Adj. Area:
QUANTITY
DESCRIPTION
FEE
a
U
U
w
w
c�
z
in
J
a
t
x
U
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
``�'
s w- D 9
INSPECTION FEE:
ISSUANCE:
/
V31p• t2--
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE-ALT FEE:
2-w
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
`� o
P/C: PAID BY: /� �►'] VALIDATION:
RECEIPT # &3' 0 1 PAID BY: 3 LEI i'7 VALIDATION:
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS:
CERTIFICATE OF INSTALLATION
CF2R-MCH-01-E
Space Conditioning Systems, Ducts, and Fans
(Page 1 of 7 )
Project Name: 1500 Shale Hollow Ln.
Enforcement Agency: City of Diamond Bar
Permit Number:
PR16-2920
Dwelling Address: 1500 Shale Hollow Ln.
City: Diamond Bar
Zip Code:
91765
A. General Information
01
Dwelling Unit Name
1500 Shale Hollow Ln.
02
Climate Zone
9
Dwelling Unit Total Conditioned Floor
Number of Space Conditioning
03
Area (ftZ)
1500
04
Systems in this Dwelling Unit.
1
05
Certificate of Compliance Type
Prescriptive alterations (CF1R-ALT)
06
Method used to Calculate HVAC Loads
ACCA_ManualJ
07
Calculated Dwelling Unit Sensible
42000
08
Calculated Dwelling Unit Heating Load
72000
Cooling Load (Btuh)
(Btuh)
09
Dwelling Unit Number of Bedrooms
3
MCH-01b Space Conditioning Systems Ducts and Fans - Prescriptive Alterations
B. Space Conditioning (SC) System Information
O1
02,
03
04
05
06
07
08
09
10
CFA served
Is the SC
Installing a
Installingnew SC
Installingmore
InstallingInstalling
Identification or
Location or Area
by this SC
refrigerant
system
than 40 feet of
entirely new
entirely new SC
Alteration Type
Name
Served
System (ftZ)
ducted
containing�
components?
ducts?
duct system?
system?
system.
component.
Altered space
System 1
Location 1
1500
Yes
No
Yes
No
No
No
conditioning
system
Registration Number: 216-A0481796A-M0100002B-0000 Registration Date/Time: 2016-12-30 11:35:35 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2016-12-30 11:35:09
CERTIFICATE OF INSTALLATION CF211-MICHI-01-E
Space Conditioning Systems, Ducts, and Fans (Page 7 of 7 )
Documentation Author's Declaration Statement
1.1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: ('1
Ricardo Felix
C1'/ [i
Company:
Signature Date:
Inspector Felix
2016-12-30 11:35:11
Address:
CEA/ HERS Certification Identification (if applicable):
335 Austin Way
City/State/Zip:
Phone:
1909-276-5090
Upland CA 91786
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Installation is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design, construction, or installation of features, materials,
components, or manufactured devices for the scope of work identified on this Certificate of Installation, and attest to the declarations in this statement (responsible builder/installer), otherwise I am an
authorized representative of the responsible builder/installer.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation conforms to all applicable codes and regulations, and the
installation conforms to the requirements given on the plans and specifications approved by the enforcement agency.
4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of construction or installation identified on this Certificate of
Installation, and I have ensured that the requirements that apply to the construction or installation have been met.
5. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all
applicable inspections. I understand that a registered copy of this Certificate of Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Joshua A Mora
B�f�lRi/�I Zl>ri
Company Name: (Installing Subcontractor or General Contractor or Builder/Owner)
Position With Company (Title):
CJD CONSTRUCTION SERVICES INC
Manager
Address:
CSLB License:
416 S VERMONT AVE
843843
City/State/Zip:
Phone:
Date Signed:
GLENDORA CA 91741
626-335-1116
2016-12-30 11:35:35
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider responsibility for the accuracy of the information.
Registration Number: 216-AO481796A-M0100002B-0000
Registration Date/Time: 2016-12-30 11:35:35
HERS Provider: CalCERTS
CA Building Energy Efficiency Standards- 2013 Residential Compliance Report Version: 2013 Rev 1.008 Report Generated: 2016-12-30 11:35:09