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Home My WebLink AboutPR16-28612E cc a z 0 0 U) J CN to 0 a 0 co rr 0 LL CITY OF DIAMOND BAR • , ,W ' 11 PIN/11M 1i 11M11 DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES p] 21810 Copley Drive, Diamond Bar, CA 91765 PRESS (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov FIRMLY JOB SITE ADDRESS faa 5affOU Lau✓' APN LOT TRACT OWNER &0 4, h �li� t 1 -5,yt ADDRESS J CITY ZIP TEL. APPLICANT D ati� � TEL.I UIQL)i LS log CONTRACTOR ADDRESS on+3 CITY ZIP ! CF 1 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 Cade: 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 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' Slate 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 resided for at least one year prior to completion of the improvements covered by this permit,) 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 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 provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine a(nd�Professions Code,, and my license is infullforce and effect. LICENSE CLASS: 3 S/ LIC. NO.: (p 1031 y z , Ci'1 EXP.DATE: I CONTRACTOR: r e WORKER'S 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 Worker's Compensation, as provided by Section 3700 of the Labor Code, 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 1. `S CARRIER w POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $1 DO OR L SS). I certify that in the performance of the work f hich this permit is issued, I shall not employ any person in any manner so a; to become subject to the Worker's Compensati ws of California. And agree Nat if I should become subject to the Worker's Comp safi n pr vi 4ns of Section 3700 of th or Code, I shall forthwith comply with those provisions. DATE: ` APPLICANT: WARNING: ilure 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 purposgs. PERMITTE E (PRINT) SIGNATURE OF PERMI LDATE APPLICATION DATE: Z —1 - 1- I f� P/C# ISSUE DATE: PERMIT# : - _ FIM(a- 2 TYPE CONSTY'P -V DJ OCC GROUP: S Scope of Work 176 ) 30 If DWEL. UNITS # STORIES QAC # BED OOMS 0' DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport w Patio/Deck w Li Pool/Spa Re -Roof -Co mmercial m O Valuation: Adj. Area: QUANTITY DESCRIPTION FEE a U U w J W c� m J a ZU_ Q x U CONSTRUCTION: PLAN REVIEW: 209. 89 ELECTRIC: PLUMBING: MECHANICAL: INSPECTION FEE: ISSUANCE: 3'D • �Z SMIP: 1 CO ENERGY P/C: ENERGY PERMIT: RETENTION FEE: PRE-ALT FEE: 2,00 BASF: 11100 PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: P/C: PAID BY: OO VALIDATION: RECEIPT # 33m5 PAID BY: �!� I5 � VALIDATION: WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy CITY OF DIANi D-BAR INSPECTION RECORD COMMENTS: