HomeMy WebLinkAbout13586CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSIT
ADDRES KC
APNT
OWNER
ADDRE
CITY ZIP TEL,
APPLICANT 71 EL.
CONTRACT -
ADD S
C TEL.
ARCRIENG/
DESIGNER 1v f-•
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS U.
CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.8 BUSINESS AND PROFESSIONS CODE: ANY CITYOR
OOUNTY WHICH REOUIRESA PERMtTM CONSTRUCT,ALTER IMPROVE. DEMOUSK OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE. ALSO REQUIRES 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 UW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE) OR THAT HE OR SHE 15 EXEMPT THEREFROM AND THE BASIS FORTHEALLEGED EXEMP-
TCN. ANY VIOLATION OF SECTION 7031.8 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
O L ASOWNEROF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFESSIONS OOOE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR VM
IMPROVES THEREON. AND O DOES SUCH WORK HIMSELF OR HERSELFOR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE 6, 1CWEVERTHE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE.
TION, THE OWNERJIUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF HAVE
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI•
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
LWK)CONTRACTSFOR SUCH PROJECTSWITHAOONTRACTOR(5) LICENSED PURSUANT TOTHE CONTRAC.
TORS LICENSE LAW.).
D 1 AM EXEMPT UNDER SEC. S. i P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
S Y LICENSE
IS I WITH S ) OF DIVISION 30F THE SM�'�ESSION
W LX;EI/SE IS N FULL CE D EFFECT -70
LICENSE CU55 UC. NO.
.15
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 NER®Y AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I HAVE AND WALLMANTAN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED SY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR W HIGH THIS PERMIT IS ISSUED.
_'HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOUIREO BY SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLIOYNUMBER
PHIS SECTION NEED NOT BE COMLE1EDOFT/E PERMIT 6 FOR ONE HAOREDDMILARS (3100) OR LESSL
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO 8ECOME SUBJECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECT PO N 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH T OSE PROVISIONS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERT COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (3 100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGE AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 30". CIV. C.).
LENDERS NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE IS APPLICATION ANDSTATE-THEASOVEI 0 ATIONISOORRECT.
I AO REE TO COMPLY TH Cffl'AND COUNTY ORDINANCES AND STAT LATNGTOSULDING
CONSTRUCTION HE Y AUTHORIZE REPRESENTATIVES 0 F 7Y TO E� E
ABOVE-MENT ERTYFO SP CTKXN PURPOS
P&MrTTEENAME IP T)
SIGNATURE OF PERMITTEE DATE
PRESS
FIRMLY
APPLICATION
PERMIT-�2,
p/ _7 P/C
DATE
NUMBER
C�Vq
ISSUE �rj, (�
_!
TYPE
OCC
DATE 1
CONST.
GROUP
ZONING SETBACKS
FRONT
RW ❑
REAR
❑
SIDE/SIDE STREET
RW ❑
SIDE
❑
PROPOSED USE
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NO. DWEL NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF ADJ. AREAIVALUATION
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to
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Palla(Deck
VL
Pool/Spa
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ADJ.AREA
OUANTITY DESCRIPTION
FEE
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PLUMBING
MECHANICAL A
INSPECTION FEE
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ISSUANCE
SMIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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%
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COMMENTS
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RECPT. NO. PAID BY
VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—file Copy, GREEN—Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
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TEMP POWER
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ROUGH GRADING
ROUGH PLUMBING
FINISH GRADING
SHOWER,fTUB 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
SEEP PIT/L.L.
GAS AIR TEST
FINAL CONST,
F;NAL HEATING
,
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LANDSCAPE/IRRIG.
ON SITE IMPS.
FINAL ZONING
FIRE DEPT. FINAL
HEALTH DEPT. FINAL
,NAL ELECTRIC
j DEV. FEES PAID
:7IMAL PLUMBING -
ENERGY
SEPTIC TANK SIZE
SEEP PIT/U SIZE