HomeMy WebLinkAboutPR17-0088a
DIA,�IO�D BAR
rCITY OF DIAMOND BAR
DEPARTMENT OF COMM UNITY'&' DEV ELOPM ENT SERVICES
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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 ] - 1 50 J K
APN — LOT TRACT
OWNER _ _ , h 1 r U I,/
ADDRESS � j�"I s.
CITY 11n�1y,%,4 8ty ZIP g11b`1 TEL.b14 3bg q7_1L
APPLICANT TEL.
CONTRACTOR GC I Sol U 'r P S'q/
ADDRESS 17 S -1 C4Cq I I OLIio:V 11%
CITY <:i4i C.%c. ZIP �/26fIi TEL. JT I Zb3 14,,L70
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 reasons)
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 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 I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sec' n
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of prope ho
builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contracto 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 r ded for at least one
year prior to completion of the improvements covered by this permiLl cannot legally sell a structur that I have built as an
owner -builder if it has not been constructed in its entirety by licensed contractors. I under and that a copy of the
applicable law, Section 7044 of the Business and Professions Code is available upon requ when this application is
submitted or at the following Web site: http/www.leginfo.ca.gov/calaw.html.
LICENSED CONTRACTOR'S DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of Chapte (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is in full force effect.
LICENSE CLASS: C LIC. NO.: tt (� 1
EXP.DATE: CONTRACTOR:
WORKER'S COMPENSATION DEC ATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOW DECLARATIONS:
1 have and will maintain a Certificate of Consent to Sel nsure for Worker's Compensation, as provided by
Section 3700 of the Labor Code, for the performance o he work for which this permit is issued.
I have and will maintain Worker's Compensation Ins nce, as required by Section 3700 of the Labor Code, for
the performance of the work for which this per
issued. My Worker's Compensation Insurance Carrier and
Policy Number are: '``
CARRIER e L111 V /I P_ we, }er I
POLICY NUMBER ATW 0(-- ' 5 Z — 6v
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS $100 OR LESS).
1 cerllfy 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 addifion 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 purposes.
PERMI E AM (PR
S16NATQPIVF PERMITTEE - Y1 DATE
APPLICATION DATE: IZ I I-
ISSUE DATE: I Z I PERMIT# :
TYPE CONST.
P/C# P RI p
— 00 8L
OCC GROUP:
Scope of Work d f A 0:1 t t C G -.A tl,j
# DWEL. UNITS # STORIES # BEDROOMS
DESCRIPTION
SQ. FT.
FAXOR PSF
ADJ. AREANALUATION
SFR/ADD/REM
Garage/Carport
ou
w
Patio/Deck
w
LL
Pool/Spa
ZRe
-Roof
Commercial
m
Valuation:
Adj. Area:
QUANTITY
DESCRIPTION
FEE
a
U
c�
w
J
W
c�
z
m
J
a
J
Z_U
Q
x
U
CONSTRUCTION:
PLAN REVIEW:
ELECTRIC:
PLUMBING:
MECHANICAL:
INSPECTION FEE:
ISSUANCE:
.3C0 • ( Z
SMIP:
ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
PRE-ALT FEE:
Z • 00
BASF:
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES
COMMENTS:
100.01
P/C: PAID BY: C.Cag VALIDATION:
RECEIPT # Sa Q'C" PAID BY: VALIDATION:_
WHITE — Department Copy, YELLOW — Finance Copy, PINK — Assessor Copy
CITY OF DIAMOND BAR
INSPECTION RFCORD a
COMMENTS:
t>> WC 04 00 01
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed.10-1
INFORMATION PAGE
Republic Underwriters Insurance Company
Insurer ID No(s). 24538
1. Named Insured: Are Servlof Orange County
Mailing Address: 1757 Galloway Lane
Corona, CA 92881
Policy No. ATW 009052-00
Prior Policy No.
Email Address: sharon.beyler@mail.aireserv.com
FEIN: 32-0414980
Intra/Interstate Risk ID No: 8856805
Other workplaces not shown above: See Schedule of Locations
_LLC
_Individual
x Corporation
_LLP
Partnership
_Other:
to 01-18-2017 12:01 A.M. standard time at the
2. The policy period is from 01-18-2016
insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: CA
ce: Part Two of the policy applies to work in each state listed in Item 3A. The
B. Employers Liability Insuran
limits of our liability under Part Two are:
Bodily Injury by Accident $1 000 000 each accident
Bodily Injury by Disease $1 000 000 Policy
Bodily Injury by Disease $1 000 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
NONE
D. This policy includes these endorsements and schedules:
See Scheduled of Forms
4. The premium for this policy will be determineed by our Manual of
rification aand change byRules.
Classifications Rates and Rating Plans.
All information required below is subject to v
Rate Per Estimated
Code No. Classifications Premium Basis of Annual
Remuneration
Estimated Annual RemOuneration Premium
See Schedule of Classifications
Experience Modification: 1.00 Total Estimated Annual Premium:
Deposit Premium:
Minimum Premium: $750
Countersigned By:
Premium Adjustment Period:
Producer Information: International Facilities
Services
S. Grand Ave
500, Suite 2100 Insurance Los Angeles, CA 90071
Servicing/Issuing Office: At General Insua2e Sees Date: 1/20/2016
/ 4365 Executive Drive Suite 400
3 San Diego CA 92121_
Ra��n n��`j'er
A
R'E'SCONDITIONINGHEATING & AIR
October 5, 2016
Frank Cruz of Cal Star Energy (and any of his employees) have my
permission to act upon Aire Sery of Corona/ Orange County's behalf
to pull permits and obtain business license.
Sharon Beyler
BCI Solutions Inc
Dba: Aire Sery of Corona/Orange County
1757 Galloway Lane
Corona CA 92881
License 985071
1
`Breathe Easy'
--
951-893-4121
714-983-0010
949-885-0155
httO://orangecounty.aireserv.com/
Aire Serv® of Orange County/Corona • "Your Comfort Company®" 9 951-893-4121 - Fax 951-273-0920
California All Purpose
Certificate of Acknowledgment
A Notary Public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached; and not the
truthfulness, accuracy or validity of that document.
.State of Calif is
County of V� � �ss
On..V' —, A 1 U LffA
fore me, c �
Date _ , (Here ' gert name and title of the
public, .personally
appeared 7X who proved to me on the basis of
satis" ctory evidence to be the person hose n ) re subscri to the within in ment and acknowledged to me that
he�they a eauted the same in hi he eir autho ' ed cap city ' s), and that by hi a heir signature
'OKrl the instrument
the person( or the entity upon behalf of which the peonrs1 acted, executed the in ment.
I certify under PENALTY OF PERJURY under the laws of the State of Calitomia
that the foregoing paragraph is true and correct.
WITNESS my ha qNoublic
"'seal.
Signature G.........
Signature of
(Notary Seal)
Title or Type of
l Document
Document Date_
Name of Signer
Title(s)
Sinner is representing:
SHELBY LFAFSTONE
COMM. #2014890 N
e- a Notary public catitomis
jB "� ` RIVERSIDE COUNTY
to MAR. 25, 2017
My Comm. W.
OPTIONAL SECTION—_____
DESCRIPTION OF ATTACHED.DOCUMENT
Number of; pages.
CAPACITWES) CLAMED By SIGNFIR
(Effective 1.1 2015) .California Acknowledgment