HomeMy WebLinkAbout18097 _ �X �►�1
_ _�� _ CTI'Y OF DIAMOND BAR
DEPARTMENT OF COIvIIvIUNITY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRE$$ I
��'%���� BUILDING PERMIT APPLICATION FIRMLY
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p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEFEBV AFFIRM UNDEFi PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f8JB/CefPOff
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w NRE.PRIOR TO ITS ISSUANCE,AL50 REDUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w P8�10/DBGC
� STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(C}IAPTER e(COMMENCINO WITH SECTION�000)OF�IVISION 3 OF THE BUSINE55 M!D PRO� � POOUSPB
� FESSIONSCODE�ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEOEDE%EMP- (�
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A CNIL PENALTV OF NOT A/ORE THAN FNE HUNDRED DOLlARS(f500).):
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WIIL DO THE WORN,AND THE STRUC7URE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7a1,BUSb J COrtlmefCl01
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� NE55 AND PF70FESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � �f'
PROPERTY WHO BUILAS OR IMPROVES THEF7EON,AND NTiO DOES SUCH WOfiN HIMSELF OR HERSELF OR v
wTHROUGH MIS OR HER OWN EAIPLOVEES,PROVIDED THAT SUp1 IMPROVEMENTS ARE NOT INTENDED OR m
0 OFFEREDFORS/�LEIF,HOWEVER,7HEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCAMPLE�
Z TION,THE OWNER�BUILDER WILL HAVE THE BUfiDEN OF PROVINQ 7}UT HE OR SHE DID NOT BUILA OR
� IAIPROVE FOR THE PURPOSE OF SALE).
w ❑I,AS ONTJER OF THE PROPEHTY,AM EXCLUSNELV CANTRACTINQ WITH LICENSED COPlTMCTORS
� TO CONSTRUCT 7HE PR0.IECT(SEC.70N,BUSINESS AND PROFESSIONS CADE:7HE CONTMCTORS LI- VBIIIeIlOf1 ADJ.AREA
W CENSE UW DOES NOTAPPLV TO AN ON?JER OF A PROPERTV WFiO BUILDS OR IMPROVES THEREON,AND
� WFiOCANTRACTSFORSUCHPRQIECTSWITHACANTRACTOR(S)UCENSEDPURSUMITTOTHECONTRAC- QUANTITY DESCRIPTION FEE
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� ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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� DATE OWNER ¢ �
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDEH PEN/�LTV OF PERIURV THAT I AM UCENSED UNDER PROVISKKJS OF CHAPTER �
� 8(COA/MENCIN(3 WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
��� MY UCENSE IS IN FULL FOflCE AND EFFECT. m
� LICENSE CLASS LIC.NO. �
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� WORKERS'COMPENSATION D C T �
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N I HEfiEBV AFFIRM UNDER PENALTV OF PERIURV ONE OF THE OWING DECLARATqNS: Z
Z� I HAVE AND WILL MAMTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' a �
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COMPENSATION,AS PROVIDED BV SECTION 370o OF THE LABOR CODE.FOR THE PERFORMANCE U
Q OF THE WORK FOR WHlqi TMIS FERMIT IS ISSUED. � `
W �I HAVE M!D WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REWIRED BV SECTION ///���
Q 37000FTHELABOFCOOE,FORTHEPEflFORMANCEOFiHEWORKFORWHICHTHISPERMITIS G'\:
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION � \J
� CARRIER �T����� PLAN REVIEW
Z .POLICVNUMBER l Z 7���2� ELECTRIC
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� (RRSSECTIOh1NE�NO7BE�A�I.ETEDOF71-IEPERMTISFOHONEFiIN.OfiED�OILARS(f100IORLESS} PLUMBING "
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C.�} SHALL NOT EMPLOY PNV PERSON W ANV MANNER 50 AS TO BECAME SU&IECT TO THE
' [/� WORICERS'COMPENSATION LAWS OF CALIFORNIA�ND AGREE THAT IF I SHOUID BECAME INSPECTION FEE I r�
SUBJECT TO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
s CODE,I SHALL FORT4iW17H COMPLV WITH THOSE PROVISIONS. ISSUANCE
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DATE: APPLICANT: SMIP
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J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFIJL,AND SHALL BE ENERGY P/C
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� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(5100.000),IN PDDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3100 OF THE IABOR CODE,INTEREST,AND ATTORNEI"5 FEES. -
OC RETENTION FEE: �
OCONSTRUCTION LENDING AGENCY PRE•ALT FEE:
� I HEREBV AFFIRM UNDER PENAL7V OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AOENCV
� FOR THE PERFORMANCE OF THE WOR7C FOR WHICH THIS PERMIT IS ISSUED(SEC.70Y7,CIV.C.�. ^.
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� LENDEFYSNAME n�_ /y- Jr/J• �'
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� LENDER'SADDRESS
w I CERTIFY THAT I HAVE READ 7HIS APPIICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL F E ES �, � ���
� I AOREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMEN S
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� SIONATUFEOFPERMITTEE DATE
= RECPT.NO. PAID BY VALIDATION
~ � WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR D—File Copy,GREEN—ApplicanYs Copy
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GROUND PLUMBING _ _ UNDER FLOOR•CU�IDUIT� ' . � �� � .��`•, '" ; •-;.
SLAB GRADE FIREPL'�`C��FOl1NDATION ' �• '` ''
TEMP PaWER FIREPLACE BOND BEAM r � � ��
WATER SERVICE _ M!D HT. 80ND BEANI , , , . ,
ROOF SHEATNING � �� ,; .. �� ' 8 FT. BOND'BEAM• • �; ._ . , }.' .
FRAMINGNENTILIATION FINAL BOND BEAM �
ROOF COVER PRE-GRADING '
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ROUGH HEATING � BENCHIN'G�' .� " . . , „ -• `- . i. °' , r� '
ROUGN ELECTRIC � ROUGH GRADING
ROUGH PLUMBING - FINISH GRADING
SHdWER/TUB TE5T PQOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
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CEILIPVG IfVSULATIOfV � OFF SITE IMPS.
DRYWALI NAIUNG ;.�i . �DEDICATIONS
SEWER F{NAL ENG. .
SEPTIC TAhlK LANDSCAPE/IRRIG.
SEEP PiT/LL. (�N SITE IMRS.
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FIfVAL CONST. ~ , �lRE DEPT. FINA!
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FItJA�ELECTRIC DEV. FEES PAID
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