HomeMy WebLinkAbout17257 (25) � �.
� CITY OF DIAMOND BAR _ ' '�
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, 21825 E.Copley Drive JUN 171001
'� (909)860-3195 Fax(909)861-3117 PRESS
��'-»����' BUILDING PERMIT APPLICATION .IUN 1 S ZQI�Z FIRMLY
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p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT I AA1 EJ(EMPT FROM THE CANTRACTORS LI- G3feJB/CBIpOft
W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITVOR (n
U CAUNTVNTIICHREOUIRESAPERMITTOCANSTRUCT.ALTER,IMPROVE,DEMOLISH,ORFiEPAIRANYSTRUC- W P81i0/DBCk
Z TURE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PEFMI7 TO FILE A SIGNED
w STATEMENT THA7 HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RACTORS LI� w
� CENSE UW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
� FESSIONS CODE)OR THAT HE OR SHE IS ExEMPT THEREFROM AND THE BASIS FOR 7HE ALLEGED EXEMP- (�
V TION.ANV VIOLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO Z Re-Roof
A CIVIL PENALTY OF NOT MORE 7HAN FIVE HUNDRED DOLLARS(5500).):
❑I,ASONMEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGES'ASTHEIRSOLECOMPENSA710N, �
Z WIIL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BU51- J Commercial -
, � NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF �
— �ROPERTVWHOBUILDSORIMPROVES7HEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR
� THROUGH HIS OR HER OWN EMPLOVEES,PROVIOED 7HA7 SUCH IMPROVEMEN7S ARE NOT INTENDED OR m
Q OFFEREDFORSPLEIF,HOWEVERTMEBUILDWGORIMPROVEMENTISSOLDWITHINONEVEAFOFCAMPLE-
Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THA7 HE OR SHE DID NOT BUIID OR
� IMPROVE FOR THE PURPOSE OF SALEJ.
❑1.AS OWNER OF THE PROPERTV.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRAC70RS
� TO CANSTRUCT THE PROJECT(SEC.7041,BUSINESS AND PROFESSIONS CA�E:7HE CONTRACTORS LI� VelUe�lOfl � ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEFiEON,AND
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� O I AM EXEMPT UNDER SEC. B.8 P.C.FOR TNIS REASON Q
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d D(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND Z
X MV LICENSE IS IN FULL FOFCE AND EFFECT. 0��
� UCENSE CLASS�/—"/ �L��r,I C LIC.N0. � � j
V DATE IO�/fl I�I CONTRACTOR_�CG d
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIfiM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECUFiATIONS: Z
� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKEHS' _
¢ CAMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE.FOR THE PERFORMANCE W
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w '` I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION �j
Q 3700 0F THE UBOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS � .7 /L
ISSUED.MY WOFIKE S'CA{Q�'PENS�.{�0 N INSUR�NCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION i�S
� CAFiRIER�A 1 Q 1 I�4 PLAN REVIEW
Z POLICY NUMBER ELECTRIC
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� (iHIS5ECf10NNEmNOTBE�OMPLETEDOFTHEPERMRISFORONEHUhDREDDOLLARS(5100)ORIESS). PLUMBING [� ` -^� '"«" '�'�"""��
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Z I CERTIFV THA71N 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL _
(.r} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SO AS TO BECO SUBJECT TO THE �
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,ANDAG T AT F I SHOULD BECOME INSPECTION FEE (�(�T 'I % 7 '
= SUBJECT TO THE WOfiKERS'CAMPEN ION PRO SION OF S CTI N 370o OF 7HE LA80R �TG—I�—-T I
COD ISHALFORTHWITHCOMPIV I OSE OVI IONS. ISSUANCE !
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DATE: � ' O APPLICANT:
� b�r 1
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEHAGE IS UN FUL,AND SHALL BE ENERGY P/C �Y � - _Y___-_ __
� SUBJECTANEMPIOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONE DREDTHOUSAND ENERGYPERMIT
DOLLARS(51ao,000),IN ADDI710N 70 THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION37080fTHELABORCODE.IN7ERE5T,ANDATTORNEV'SFEES. RETENTIONFEE:
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENAL7V OF PERJURV THAT THERE IS A CONSTRUC710N IENDING AGENCV
� FOR THE PERf-0RMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� LENDER'S NAME
F— LENDEii'SADDRESS
w I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL F E ES /G�." O
� I AGREE 70 COMPLV WI7H ALL CITY AND CAUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONS7RUCTION,AND HEREBV AUTHORIZE REPRESEN7A71VES OFTHIS CAUNTVTO ENTER UPON 7HE
Z ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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FTGS/FORMS/STEEL ; �FHA REQMTS ___—�
ELECTRIC GROUND ; UNDER F!_OOR DUCT � j
GROUND PLUMBING ; UNDER FLOOR CUt�!DUIT ______
SLAB GRADE FIREPLACE_FdUNDATiC�N _ � � _
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TEMP POWER � FIREPLAGE BQND BEAM �
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W,4TER SERVICE _ ; ____ _ __ MID HT. BOND BEAM • �
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ROOF SHEATHI(VG /���� � 8 F�'. BOND BEAM '� i
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FRAiViING/VEtJTILIATION � FINAL BOND BEAM ______ i
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ROOF COVER PRE-GRADING ;
ROUGH HEATING BENCHING �
ROUGH ELECTRIC I ROUGH GRADING
RQUGH PLUNIBING FINISN GRADING
SHOWER/TUB TEST � POOL ELECTRIC
EXT. LATH/SIDING , POOL FENCING
WALL IiVSULATION � POOL FINAL
CEILING INSULATION � OFF SITE IMPS. �
DRYWALL IUAILING DEDICATIONS '
SEWER FINAL ENG. '
SEPTIC TA(VK . LANDSCAPE/IRRIG. '
SEEP PIT/l..L. � ON SITE IMPS. �
GAS AIR TEST FINAL ZC}NING
FINAL COfVST. FlRE DEPT. FINAL
FINAL HE,4TIfVG HEALTH QEPT. FIfVAL
FINAL ELECTRIC � DEV. FEES PAID
FIPVAL PLUMBIMG � ENERGY
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