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Home My WebLink AboutPR16-2796r 3�15� �.r•:,, CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY &DEVELOPMENT SERVICES n 21810 Copley Drive, Diamond Bar, CA 91765 PRESS (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) - 27 FIRMLY BUILDING PERMIT APPLICATION www.cityofdiamondbar.com building@diamondbarca.gov JOB SITE ADDRESS a b 3a CA5rL;e Ko Clr- 12J) APN LOT TRACT OWNER ADD ES CITY Yl ZIP TEL. APPLICANT L. CONTRACTOR ADDRESS G CITYfoik ZIP TEL. A CH N D SIGNE A DIRE Cl ZIP TEL. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License La for the reason(s) ndicated below by the checkmark(s), have placed next to the applicable item(s) [Sectionm1.5, Business and Professions Code: Any city or county that requires a Permit to construct, alter, imp rov eolish. or repair, any structure, prior to i issuance, also requires the applicant for the permit to file a s'gned statement that he or she is licensed pursuan o the provisions of the the State License Law (C er 9) Commencing with Section 7000 of Division 3 of Business and Professions Code] or that he or she i empt from licensure and the basis for the alleged exemption. M iolati in of Section 7031.5 by any applicant fora,ptrmit subjects the applicant to a civil penalty of not more than five hundre ollars ($500). elf (, I, as owner of the property, o y employees with wages as t sole compensation, will do (, all of or (, portions of the work, and the stmcture is n intended or offered for a (Section 7044, Business and Professions Code: The Contractors' State License Law does no ply to an owner property who, through employees' or personal effort, builds or improves the property, provided that the roveme are not intended or offered for sale. If however, the building or improvement is sold within one year of comple 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 exclusiv contra g with licensed Contractors to construct the project (Section 7044, Business and Professions Code: T Contractors' St License Law does not apply to an owner of property who builds or improves thereon, and who cc racts forthe projects w a licensed Contractor pursuant to the Contractors' State License Law.). U I am exempt from licensur nder the Contractor's State License la or the following reason(s): Date: Sign:' By my signature below I knowledge that, except for.my personal residence in Nsestructure ave resided for at least one year prior to completi of the improvements covered by this permit,) cannot legthat I have built as an owner -builder if snot been constructed in its entirety by licensed conterstand that a copy of the applicable law, Section 7044 of the Business and Professions Code is availabst 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 Bu siness and Professions Code, and my license is in full forand effect. LICENSE CLASS. v ,3 LIC. NO.: EXP.DATE CONTRACTOR: r WORKER'S COMPENSA ION 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. 1 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 ar : 1,3 CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 9R LESS). o ny I certify that in the performance of the work for which this permit is issued, I shall not employ any permanner so as to become subject lot Worker's Compensation Laws of California. And agree that if I should be a subject to the Worker's Compensation provisions ection 3700 of the Labor Cade, I shall forthwith comply with t provisions. DATE: AP ANT: WARNING: Failure to secure Worker ompensation coverage is unl ,and shall subject an employer to criminal penalties and civil fines up to one hundr housand dollars 000), in addition to the cost of the compensation, damages as provided for in section 3708 of the r code ' rest, and attorney's fees. CONST Ben LENDING AGENCY I hereby affirm under penalty of perjury th en: is a Constr n Lending Agency for the performance of the work for which this permit is issued (Sec. 30 , w. 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 enterupo the bove-mentioned pro ertyforinspection purposes. r PERMITTEE SIGNATURE dT'PEMiT1kT DATE I t APPLICATION DATE: P/C# ISSUE DATE: 12/I4A/ ( ro p PERMIT# : f K1160— 2—+9cp TYPE CONST. OCC GROUP: Scope of Work a. J A�� # DWEL. UNITS # STORIES # BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport w Patio/Deck - Lu LL Pool/Spa ZRe -Roof � Commercial 10 m Valuation: Adj. Area: QUANTITY DESCRIPTION FEE a U r— w w co z m a ZU_ Q x U CONSTRUCTION: PLAN REVIEW: ELECTRIC: _ PLUMBING: ��• (oZ_ MECHANICAL: INSPECTION FEE: QQ ISSUANCE: SMIP: ENERGY P/C: ENERGY PERMIT: RETENTION FEE: Z• �� PRE-ALT FEE: BASF: PLOT PLAN: ZONING CLEARANCE: TOTAL FEES COMMENTS: P/C: PAID BY: VALIDATION: RECEIPT p 32 95 PAID BY: VALIDATION: WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy CITY OF DIAMOND BAR INSPECTION RECORD COMMENTS: DATE (MMIDDlYYYY) '°`�� `'' CERTIFICATE OF LIABILITY INSURANCE 11/28/2016 11/28/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER -CA T Cr Sarah Rolston Bell Anderson Agency, Ino. PHONE- (425) 291-5200 FAX (425)291-5100 600 SW39th $t, Suite 200 'pI s.earahrObell-anderson.com INSURERS AFFORDING COVERAGE NAIC 0 Renton WA 98057 SURERA:Liber Mutual Fire Insurance 23025 INSURED EM Acquisition Co LLC, DBA: Fast Water Heater CO INSURER B: 11715 North Creek Parkway S #C:-106 INSURERC: INSURER D: INSURER E : Bothell WA 98011 INSURER F: ------ KCVIDIUN NUMtftK: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD. INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED -BY PAID CLAIMS. LS TYPE OF INSURANCE POLICY NUMBER POLICY EDYYFY POLICY NYD ! YYY LIMITS EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE0 OCCUR A occu ra ce . occu ra ce . S Sa MEDEXP .one Person) �a S PERSONALBADVINJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JET LOC OTHER: GENERAL AGGREGATE S PRODUCTS -COMPIOPAGO. S S AUTOMOBILE LIABILITY ALLOWNENY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUT03 COM& E SI a cle $ BODILY INJURY (Per pa�son) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE P. $ A000 UMBRELLA LIAR EXCESS LIAB OCCUR NIA I9C2691464565025 12/1/2016 12/1/2017 EACH OCCURRENCE S' HCLAIMS-MADE AGGREGATE $ D D 1, 1 RETENTION WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) tt V69 describe under DESCRIPTION OF OPERATIONS below PER 0 - STATUTE I I ER S E.L. EACH ACCIDENT S 1,000,000 , E.L. DISEASE- EAEMPLOYEE $ 1,000,000 .EL DISEASE - POLICY LIMBS 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H Moro space Is required) Re: Stridence of Insurance/contractore license #987398 / DVM65mP nc12TIG1^AT0 ll/11 1�t•e9 State of California Contractors License Board P O Box 26000 Sacramento, CA 95826 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE James_ Hunt/SMD 01988-2014 ACORD CORPORATION. All rights &. I&V I4ru I I me ACORD name and logo are registered marks of ACORD INSO26 nM+4M11