HomeMy WebLinkAbout149911111A111U NIU.
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660E. Copley Drive Stria 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 2-3 53:2
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APN LOT TRACT
OWNER LP�
ADDRESS
CITY ZIP —TEL c
APPLICANT TEL
CONTRACTO G'
ADDRESSYa 7/ 1ZT
CITY 4 ZIP TEL 40 Z 3u
ARCRTNG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERAIRY THAT IAM EXEMPT FROM THE CONTRACTORS LI•
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.4 BUSNESSAND PROFESSIONS CODE: ANY CRY OR
ODUNTYWHILTH REOUIRESAPERMTTTO CONSTRUCLALTER IMPROVE, DEMOUSH.OR REPAIRANY STRUC-
TURE. PRIOR TO RLSO S ISSUANCE, AREWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER I (COMMENCING W17H SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS WOE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.4 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).):
0 L AS OW NEROF THE PROPERTY. OR MY EMPLOYEES NTH WAGES ASTHMS SOLE COMPENSATION,
WILL DO 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 BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALEIF, HOWEVERTHE BULDNGOR IMPROVEMENT:S SOLD WITHNONE YEAROFCOMPLE-
T10N, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FORTHE PURPOSE OF SALE)
O L AS OWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CON7RACTORS U.
CENSE LAW DOES NOTAPPLYTO AN OWNER OFAPROPERTY MRO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH TO
1W THA CONTRACTORS) LICENSED PURSUANT TOTHE CONTRAC-
TORS
ONTRAOTORS LICENSE LAW.I-
O 1 AM EXEMPT LINDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PER.AIRY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
I (COMMENCING WITH SECTION 7000) OF OrASK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,ANO
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0. �Z
DATE^2.2= — �CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I RAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-NSURE FOR WORKERS' I
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFOnMANCE
OF THE WORK FOR WHICH THIS PERMIT R ISSUED.
�I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS RE WIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' ODMPENSATIDN INSURANCE CARRIER AND POLICY NUMBER ARE-
CARRIER
RECARRIER
POLICY NUMBER
011,
'\1 710` .tR/SSECIIONNEEDNOTBEOOS'LETEDOFTHE ?�� T jIST,ODIORtESS)SHALL NOTT EMPLOYNANYEERSON NN ANY MANNER SOAS �$I��, VtMMJJjjTTT T�GTHE-' 1��•�
WORKERS' COMPENSATION LAWS OF CAL/FOFINIA, ANO ACRES TRAT CF6f10TILD BEODME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
WOE. I' Z .L -4M 7TH WWITH
DATE: �':LIPPLICANT.CJINT.
WARNING: FALURETO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL.ANDSHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (1100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
BECTON 4708 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3097. CV. O1.
LENDERSNAME
LENDERS ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THEAROVE INFORMATION IS CORRECT.
1 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.MENTONEO PROPERTY FOR INSPECTION PURPOSES.
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PERMI EE NAME (PRINT) _ yn
SIGNATURE 6F PrWITTEE C� DATE
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NO. DWEL
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UNITS
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DESCRIPTION SO. FT. FACTOR PSF
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ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENTS
RECPT. N0.
PND BY ALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—Filo Copy, GREEN--ApPIicaM'3 COPY
CITY OF DIAMOND ;BAR. _
INSPECTION RECORD
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UNDER FLOOR CONDUIT
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FIREPLACE. -FOUNDATION
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FIREPLACE BOND BEAM
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ROUGH GRADING
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FINISH GRADING
SHOWER/TUB TEST
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POOL'ELECT.RIC.
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POOL'FENCING
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POOL FINAL
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OFF SITE IMPS.
,DRYWALL'NAILING
DEDICATIONS
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;SEPTIC TANK
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ON SITE IMPS.
GAS AIR TEST I
;FINAL CONST...;.-.-.
FINAL HEATING I
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FINAL ZONING
j FIRE DEPT. FINAL
HEALTH DEPT. FINAL
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;FINAL ELECTRIC
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DEV, FEES PAID
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;FINAL PLUMBING
ENERGY
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(SEPTIC TANK SIZE
SEEP PIT/U SIZE _
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