HomeMy WebLinkAbout17636 (25) CTI'Y OF DIAMOND BAR 1 1 ��
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p� OWNER-BUILDER DECLARATION SFR/AOD/REM
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, � I HEREBV AFFIRM UNDER PENALTY OF PERJVRV THAT I AM E%EMPT FqOM THE CONTRACTORS LI� G8f9 B/C8 OR
W CENSE UW FOR THE FOLLOWINO REASON(SEC.7031.5 BUSINESSAND PROFESSIONS CODE:ANV CITV OH (n 9 � �
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w TURE.PRqR TO ITS ISSUANCE,/�150 REOUIRES TNE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED w P8110/DBCk
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFOVISIONS OF THE CONTRACTOFS LI� ,
� CENSE UW(CMAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
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V TION.ANVVIOLATIONOFSECTION7o31.5BVANVAPPIICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
A CIVIL PENAL7Y OF NOT MORE iH/W FIVE HUNDRED DOLLARS(f500).):
� OI,ASOWNEROFTHEPROPERTY,ORMVEMPIOYEESWITHWA0E5A5TNEIRSOLECAMPENSATION, � COrt1rtIBfC18I
Z WILL DO TFIE WORK,AND 7HE S7RUCTURE IS NO7 INTENDED OR OFFERED FOR SALE(SEC.704�,BUSI� J ��
N NESS AND PqOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ?
PROPER7Y MT10 BUILDS OR IMPROVES THEFEON.AND YhlO DOES SUCN WORK HIMSELF OR HERSELF OR
� THRIX1aH HIS OR HER OMM EMPLOYEES,PROVIDED THAT SUCH IMPqOVEMENTS ARE NOT WTENDED OR m
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Z TION.THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w ❑I,ASON7JEROFTHEPROPER7Y.AME%CLUSIVELYCONTRACTINOWITHLICENSEDCONiRACTORS
[= TO CONSTRUCT THE PROJECT(SEC.701a,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V8IU3flOf1 ADJ.AREA
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Y 70RSLICENSEUW.).
� ❑I AM E%EMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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� DATE OWNER H
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�Q LICENSED CONTRACTORS DECLARATION W
CC I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSED UNOER PROVISIONS OF CHAPTER U.
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��� MY LICENSE IS IN FU'LpL FORCE M1D EFFECT. m
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� WORKERS'COMPENSATION DECLARATION `�`� Q {�
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� I HEREBV AFFlRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWINO DECURATIONS: Z
�Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR V/ORKERS' a
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COMPENSATION,AS PROVIDED BY SEC710N 370o OF THE LABOR CODE,FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. W
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W ��HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION ^
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS [� �C'�
ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIER AND POLICV NUMBEH ARE: CONSTRUCTION
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� (1FCSSECTqNNE�NOTBEOQMPLFfEDOFhfPEW.YTISFORONEh�,l�EDDOILrRi(f100)OFiLESS). PLUMBING S
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Z I CERTIFV THAT INTHE PERFORMANCE OF THE MlORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C} SHAIL NOT EMPLOY ANV PERSON IN ANV MANNER 50 AS TO BECOME SU&IECT TO THE
(/7 WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOUID BECOME INSPECTION FEE
= SU&IECTTO THE WORKERS'COMPENSATION 7ROVISIONS OF SECTION 31000F THE LABOR . [�
CODE.ISHALLFORTHWITHCOMPLVWITHTFqSEPROV151 S. �SSUANCE ,�JtJ
p DATE:O�� I�O� APPLICANT: SMIP c `na
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� WAANINO:FAfLURE TO SECURE WORKERS' NSATION CO AGE UNUWFUL,AND SHALL BE ENERGY P/C
�y SUBJECTANEMPLOVERTOCRIMINALPEN SANDCMLFINES ONEHUNDREDTNOUSANO ENERGYPERMIT
DOLLARS(5100.000).IN ADDITION TO THE COST OF fAMPENSATION,DAMAGES AS PfiOVIDED FOR IN
J SECTION 37oB OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
OC RETENTION FEE: � � D
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: /� �
� I HEPEBV AFFlRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AOENCV r
FOF THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.CJ.
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� LENDER'S NAME
F— LENDEfl'SADDRESS
w ICERTIFVTHATIHAVEREADTHISAPPLICATlONANDSTATETFIATTHEABOVEMFORMATqNISCARRECT. TOTAL FEES �
� I AGREE TO CAMPLV WITH ALL CfTV AND CWNTY ORDINANCES AND STATE LAWS RELATINO TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF 7HI5 CWMV TO EMER UPON THE
Z ABOVE�MEMIONED PROPERTY FOR INSPECTION VURPoSES.
o COMMENTS
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m PEFMI NAME(PRIN17
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� I REOFPERMITTEE DA7E
� RECPT.NO. PAID BY VALIDATION
HITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL ' , � FHA REQMTS
ELECTRlC GROUND UNDER FLOOR DUCT •
GROUND PLUMBING UN�EF� FLOOR CUf�IDU►T �
SLAB GRADE � � FIREPLACE FOUNQATION
TEMP POWER FIREPLACE BOPJD BEAM
WATER SERVICE MIQ HT. BONQ BEAM i
ROOF SHEATHIIVG � 8 FT. BONQ BEAM
FRAMfNG/VENTILIATION �Z�%z „s�� � FINAL BOND BEAM
ROOF COVER PRE-GRADIl�1G .
ROUGH HEATlNG BENGHING ' •
ROUGH ELECTRIC ROUGH GRADItVG
ROUGH PLUiVIBING FINISH .^aRADING
SHOWERiTUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATIOtV POOL FINAL
CEILIiVG INSUI�4TION OFF SITE IMPS.
DRYWALL NAIL.ING '���Z ' DEDICATIOtVS � �
SEWER FINAL ENG.
SEPTIC TANK , � LANOSGAPE/IRRIC,.
SEEP PIT/L..L. ' � ON SIYE fMPS.
GAS AIR TEST F1NAL Z�N1(vG
FINAL CONST. ' �!RE DEPT. FINAL
FINAL HEATING � HEALTH DEPT. FINA�
FINAL ELECTRIC � DEV. FEES PAID
FINA�PLUPVIBING I ENERGY
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CONlfi�ENTS � �
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SEPTIC TANK SIZE '
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