HomeMy WebLinkAboutPR16-2662.� 44 was- e man c 9emen+
CITY OF DIAMOND BAR
DEPARTfMENT OF COMMUNITY & DEVELOPMENT SERVICES Iri'HA
21810 Copley Drive, Diamond Bar, CA 91765 FINALIZEDPRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarea.gov
JOB SITE ADDRESS '
APN LOT T ACT
OWNER
ADDRESS <4O
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS jo0-->�
CITY ZIP EL. 1 — l2
ARCH/E G/
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 Iicensure 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 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
;?roved roved for the purpose of sale.).
s owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section
7044, Business and Professions Cade: The Contractors' State License Law does not apply to an owner of property w
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' S e
License Law.).
U I am exempt from Iicensure 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 r/tha
t least one
year prior to completion of the improvements covered by this permit,l cannot legally sell a structure built as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I understanopy of the
applicable law, Section 7044 of the Business and Professions Code is available upon request whlication is
submitted or at the following Web site: hqp/www.leginfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (comm cing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force and effect.
LICENSE CLASS: �� LIC. NO.: Gy
EXP.DATE: CONTRACTOR:
WORKER'S CO NSATION DECLARA70
'I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARAT NS:
I have and will maintain a Certificate of Consent to Self -Insure for W er's Compensation, as provided by
.Section 3700 of the Labor Code, for the performance of the work for ich this permit is issued.
I have and will maintain Worker's Compensation Insurance, as requi d by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My W er's Compensation Insurance Carrier and
Policy Number are:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IZagree
ONE HUNDRED DOLLARS $100 OR LESS).
I certify that in the performance of the work for which this permit is issshall not employ any person in any manner so as to
become subject to the Worker's Compensation Laws of California. that it 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:
1 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 insp coon purposes.
r ,
PERMITTEE N E (PRINT•)
SIGNATURE OF P I E DATE
APPLICATION DATE: ' I- 22-- 20 1 6 P/C/#- 4
ISSUE DATE: 1' - 22 - 20 * PERMIT# : 1" R_ ( (D Z
TYPE CONST. C GROUP:
A/
l0 lOZ
Scope of Work/
# DWEL. UNITS If S RIES # BEDROOMS
ee a
DESCRIPTION
SO.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
v7w
Patio/Deck
w
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Po a
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Commerc'
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Valuatiomy Adj. Area:
QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION: 115160
PLAN REVIEW:
US
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
IZ
SMIP:
42,
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE-ALT FEE:
M
lco
BASF:
(,06
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
Cl (p, (OCI
P/C: 2 PAID BY: VALIDATION: r / n
RECEIPT # . ..] 2 (Dq PAID BY: cash VALIDATION: �1..
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
UFM GkOUN'b
SEWER LATERAL
MAIN WATER LINE
SEWER CLEANOUT
ROOF SHEATHING
FLOOR SHEATHING
INSULATION WALL
INSULATION CEILING
DRYWALL
LATH (PRE)
LATH EXTERIOR
LATH INTERIOR
GAS TEST
SCRATCH COAT
ELECTRIC METER RELEASE
GAS METER RELEASE
SPECIAL INSPECTION
COMMENTS: i
CITY OF DIAMOND BAR
INSPECTION R,E,CQIRD
TRACT AND LEDGER
SWITCH GEAR
COMMERCIAL HOOD
T -BAR
INTERCEPTER
HOT MOP/SHOWERPAN
SEPTIC/CESSPOOL
HERS REPORT RECEIVED
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ROUGH CONDUIT
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WALL BOND BEAM
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