HomeMy WebLinkAboutPR17-01854 CITY OF CiAMOIND BAR
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
JOB SITE ADDRESS b q b !„ Q V1 Ve
APN LOT TRACT
OWNER An f t4 IN( 0 n
ADDRESS 1",a
CITY 0+uh+04 Ritr ZIP q 7 TEL D _%11— 009 7
APPLICANT TEL.
CONTRACTOR 00r' Do h L42
ADDRESS 1 `],s s` L e i ii n p r h l P.
CITY PSAI ZIP GS TEL. 101 S' 7$25
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP•_ TEL
.x,3�:fONkBUIL'DER DECLARATION
I hereby affirm under penalty of perjurythat 'ram 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
70DO 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 ($500).
U I, as owner of the property, or my employees with wages as their sole compensation, will do (J 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 1, 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 rat least one
year prior to completion of the improvements covered by this permil,l cannot legally sell a structure thaah built as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I understan hat a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request an this application is
submitted or at the following Web site: http/www.leginfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under pio�,sions of Cha 'er• com\ehcirii ,,w ,fiction 7000)
of Division 3 of the Business and Professions Code, and my license is in full fr:c?S e6r r
LICENSE CLASS: C + LIC. NO.: 65q06,6
EXP.DATE: l CONTRACTOR:
WORKER'S COMPENSATION DEC RATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOYJWG DECLARATIONS:
I have and will maintain a Certificate of Consent to S I -Insure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance f the work for which this permit is issued.
I have and will maintain Worker's Compensation I rance, as required by Sectwn sz00 of the Labor Code, for
the performance of the work for which this per is issued. My Worker's Compensaflun Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLEE FTHE PERMIT IS FOR ONE HUNDRED DOLLARS`F100.OR%:ESS).
I certify that in the performance of the work for which`][iis permit is issued, I shall not employ any person in any manner so as to
become subject t the W er's Compensation Lavrs of Calif ia. And agree that if I should become subject to the Worker's
Compensation p Nsi ns Scil 3700 of the Labor C d shall forthwith comply with those provisions..
DATE; LICANT: �
WARNING: ilure to secul Worker's Compen do coverage is unlawful, and shall subject an employer to criminal
penalties and civil fines up to one hundred thous d dollars ($100,000), in addition to the cast of the ^r.'."•-isabon,
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. Q.
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.
yovy) Lee
PERMITTEE NAME (PRINT) �r- f 17
SIGNATURE OF PERMITTEE DATE
FFA
APPLICATION DATE: w
ISSUE DATE:
TYPE CONST.
P/C# L
PERMIT# : 14 -018 J
OCC GROUP:
f
Scope of Work old; h 50 am 10 0 ut 7
e
# DWEL. UNITS # STORIES # BEDRO MS
DESCRIPTION
SQ. FT.
FACTOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport".
rn
w
-Patio/Deck
U_
Pool/Spa
ZRe
-Roof
J
Commercial
D
m
V ivaticn:
Adj. Area:
Q NTITY I
DESCRIPTION
FEE
J
U
w
J
w
•
z
m
a
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4
x
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CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
�S9.310
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
ats.l2
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE-ALT FEE:
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
q -70
P/C: /}PAID Ely: VALIDATION:
RECEIPT # ��3 `l. iPAID BY: �- VALIDATION:
WHITE —.Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
COMMENTS:
1869 ermeya�of Ln ,
ni amond Day, CA
ELECTRIC
MET -ER