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Home My WebLink AboutPR17-0232DIVIOND BAR yam. 0 b r' CITY OF DIAMOND BAR 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@diamondbarea.gov JOB SITE ADDRESS 0 Sy VQ ,,, v Qy e APN LOT TRACT OWNER Q �1� i i210L4eZ ADDRESS 4 .� 5/I✓ 4 G 1441 k 4 1N CITY �J►-rAlx f' �Q� ZIP / 7GSEL. $�d y6 APPLICANT TEL. CONTRACTOR ADDRESS l 0 r CITY ZIP TEL. J 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 ($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. It 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 I: w 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 1 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 Business and Professions Code, and my license is in full force and effect. LICENSE CLASS: aC LIC. NO.: EXP.DATE: CONTRACTOR: WORKER'S CO PE N D TION 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: CARRIER POLICY NUMBER I etc (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 California. 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 purpYeVI 7-ig jet. PERMITTF AME 1 RIN l / 10- SIGNATURE < R DATE APPLICATION DATE: 113O1I —4" P/C# ISSUE DATE: I O PERMIT# : P R I T- TYPE CONST. OCC GROUP: Scope of Work 141r 0, Q # DWEL. UNITS # STORIES # BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport w Patio/Deck - w u_ Pool/Spa ZRe -Roof Commercial co m Valuation: Adj. Area: QUANTITY DESCRIPTION FEE U it w w m J rL ram_ c� CONSTRUCTION: PLAN REVIEW: ELECTRIC: PLUMBING: MECHANICAL: [oI • q INSPECTION FEE: ISSUANCE: 6 � , Z SMIP: ENERGY P/C: ENERGY PERMIT: RETENTION FEE: Z . 00 PRE-ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES 100.01 COMMENTS: P/C: PAID BY: VALIDATION: RECEIPT # 33 SOS, PAID BY: VALIDATION: WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy CITY OF DIAMOND BAR INSPECTION RECORD COMMENTS: CERTIFICATE OF INSTALLATION CF2R-MCH-23-H Space Conditioning System Airflow Rate (Page 3 of 3) Documentation Author's Declaration Statement 1.1 certify that this Certificate of Installation documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Ivan Levitski O&W v Company: Signature Date: 2017-02-14 22:18:22 Airzone Address: CEA/ HERS Certification Identification (if applicable): 1432 via corta City/State/Zip: Phone: La Verne CA 91750 1909-593-4598 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 either: a) a responsible person 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, or b) I am an authorized representative of the responsible person and attest to the declarations in this statement on the responsible person's behalf. 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 Certificate of Compliance, plans, and specifications approved by the enforcement, agency 4. 1 understand that a HERS rater will check the installation toverify'compliance and if such checking determines the installation fails to comply, I -am q ' yry 'corrective action at no�char a to the building owner 1, re cared to offer an necessary corre "g g � w . 5. 1 will ensure that a registered co of this Certificate of_Instaliation s'hal6`be osted; or made available with,ffie buildin`' o ,the L g permit(s) issued for building, and made available fo 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 documentatlpn the tiuilder;provides to the building owner at occupancy. Responsible Builder/Installer Name: Responsible Builder/Installer Signature: Ivan Levitski Company Name: (Installing Subcontractor or General Contractor or Position With Company (Title): Builder/Owner) OWNER Airzone Address: CSLB License: 1432 via corta 846350 City/State/Zip: Phone: Date Signed: La Verne CA 91750 909-593-4598 2017-02-14 22:18:22 Third Party Quality Control Program (TPQCP) Status: Name of TPQCP (if applicable): 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: Registration Date/Time: 2017-02-14 22:18:22 HERS Provider: CaICERTS 217-A020040296A-000-001-M 23001 A-0000 CA Building Energy Efficiency Standards Report Version: 2016.1.005 Report Generated: 2017-02-14 22:05:23 2016 Residential Compliance Schema Version: rev 10/16