HomeMy WebLinkAbout15028 (19)CITY OF DIAMOND BAR
-�
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
' . BUILDING PERMIT APPLICATIONJOBSITE
1 _:►-oD
ADDRESS CJCJ
APN LOT TRACT ��s-
OWNER—rRA/sim L4 wi•� sOAa
ADDRESS 7iNU I
CITY L • ZIP TEL. o'
APPLICANT mLLg TEL.
CONTRACTOR
ADDRESS
CIN ZIP TEL
I/ENG/
DESst /
DESIGNER /��
ADDRES
CITY V1 ZIP 2gQtdTEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEG 70.71.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
CDUMTY WHICH REQUIRES A PERMRTOCONSTRUCf, ALTER IMPROVE. DEMOUSH, OR REPAIR ANY STAUC.
TORE, PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U -
CENSE LAW (CHAPTER 5 (COMMENCING WITH SECTION TWO) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE ORSHE IS EXEMPT THEREFROM AND THE BASIS FORTHE ALLEGED EXEMP-
TIOAI. ANY
VIOLATION OF SECTION 7031.5 BY ANYAPPUCANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).):
OLASOWNEROFTHEPROPERTY,OR MY EMPLOYEES WITH WAGESASTHEIn SOLE COMPENSATION,
VALL 00 THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO
BULDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH W PROVDMENTSARE NOT INTENDED On
OFFERED FOR SALEIF. HOWEVER THE BUILDING OR WPROVEMENT IS SOD WITT3N ONE YFJJIOF COMPILE
TRON, THE OWNER.BUILDER WILL HAVE THE BURDEN OF PROVNG THAT HE OR SHE 00 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
D LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LF
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUJDS OR IMPROVES THEREON, AND
WHDCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTORS) LICENSED PURSUANTTO THE OONTRAG
TOFISUCEH5ELAW)
D 1 A A EXEMPT UNDER SEG B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 LN
HEREBY AFFIRM DER PENALTY Of PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
f (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE ISN FUL((L��FORCEAND EFFECT.
LICENSE CRASS _t. R" L LIC. NO. 3 ` ��p
DATE s�3 r -ii > CONTRACTOR C�-�e6k r
WORKERS'COMPENSATION DECLARATIO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING CLAATION
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEL INSUREFORW'ORK RS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OFTIE LABOR E,FORTHEPERFCIUTANCE
OFTHE WORK FOR WHIcHTHIS PERMIT IS ISSUED.
1 HAVE AND WILL MANTAN WOnKERS' OOMPENSATKN INSURANCE, AS REQUIRED BY SECTION
7700 OF THE LABOR COOS, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY YORKERS- COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICYNLNEER I 57
(nH65EcnON NEED NOTBE amPLETEDOFTE PERMITIS FOR ONE1ElDRDDCLIARSI$ I
I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FORW14 THIS PERMIT SSUED.I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SOAS TO BECOME SUBJECT OTHE
WOPo(ERS'COMPENSATIDN LAWS OF CALIFORNIA AND AGREE THAT IFISHOV BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 THE LABOR
COOE, I SHALL FORTHWITH COMPL OSE PROMS( S.
DATE: rAPPLICANT
WARNING: FAILURE TO SECURE WORKERS' COMPENSATON COVERAGE IS UNLAWFUL, ANO SHALL B
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (11100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37060E THE LABOR CODE, NTERE ST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 NEWBY AFFIRM UN DER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3N7. CIV. C.).
LENDERS NAME
LENOEISADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATIONAND STATE TNT TME ABOVE INFORMATION IS CORRECT.
(AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUngRRE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERM( NAME(PRINT)
SIGNRTU FPERMITTEE 1.DATE
(T
PRESS
FIRMLY
CATION ,
a�
PERM IT
DATE
NUMBER
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
Ij77114
NO. DWEL
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
Garage/Carport
WPatio/Dock
LL
PooVSpa
0
Z
Ro-Rool
0
Commercial
5
m
Valuation
ADJ.AREA
OUANTITY bESCRIPTION
FEE
U
U
W
'
W
Ca
a
z
a
CONS UCTITII N
D
`P f •[ \
��
• e�
\E .CTI �J
LUMBING
.fay
MEC [CAL
PECTION FEE
ISSUANCE
_ v
11
rl 2N
1
-
.SMTP
i
.• o
ENERGY P/C
F...T.K
_—CTIA—
j k3F
U�
n� Fi '%l
L ` • �.,r,.+.Y
ENERGY PERMIT
] ( N"
t T
RETENTION FEE:
PRE -ALT FEE: %
T
r
L
TOTAL FEES
COMMENTS
RECPT. NO.
PAID BY
VALIDATION
WHITE --Department Copy. YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File COpy. GREEN—Applicant's Copy
CITY OF DIAMOND.RAR
INSPECTION RECORD
E lC.I It�I�L���!1.�.w•-
SET 6t= -`J
„-• -I-- — 1
-FLOOR.dQIST ',�'. �`r�
,' '� a i.
FTGS/FORMS/STEEL
FHA REQMTS -
ELECTRIC GROUND
UNDER FLpQFj DLJGT,
GROUND PLUMBING
SLAB GRADE
FIREPLACE OU!4DATION
�,' •`
TEMIP POWER -
FIF19F CEBnND BEAM
WATER SERVICE.
R Sf~itraTNING .'" '`
FRAMINGNENTILIATION �(/�D� �.
ROOF COVER (
MID HT. BOND BEAM
8 FT. BOND BEAM
FINAL BOND BEAM,-,;,!-,
PRE nRADING •
ROUGH HEATING .
BENCHING' 1 : #...I ; .
V' . �r ..:
-'ROJGH ELECTRIC
ROUGH GRADING '
ROUGH PLUMBING
FINISH GRADING.
SHOWER/TUB TEST
POOL ELECTRIC
EXT.-LATH/SIDING
POOL FENCING
WALL INSULATION
POOL FINAL
CEILING INSULATION
OFF SITE IMPS.
DRYWALL. NAILING
DEDICATIONS .
SEWER
FINAL ENG.
.SEPTIC TANK _ . ...
!'
LANDSCAPE/IRRIG.
SEEP-PIT/L.L.- .
-
ON SITE IMPS.
GAS AIR TEST'
FINAL CONST.,
FINAL HEATING
rby
�!
FINAL ZONING
FIRE DEPT. FINAL
HEALTH DEPT. FINAL
FINAL ELECTRIC
DEV. FEES PAID
FINAL PLUMBING
ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE