HomeMy WebLinkAbout16679 (78)�\ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
?-r ^ 21825 E. Copley Drive
(909) 860-3195 Fax (909) 861-3117
- BUILDING PERMIT APPLICATION
JOBSITE 1Y a-!�
ADDRESS
APN LOT TRACT
OWNER j4RaY
ADDRESS i1R.25- /_fA�JICJC;
CITY CANT(ZOR 1j ZIP Q[ TEL
APPLICANTI-'�IJ4K M1jtcrLJ1A,0TEL?42
CONTRACTOR C NAV_\S
ADDRESS '%'TCA Je'-_ NjM
CITY lr�_)A/A ZIP TEL
ARCFVENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS COCE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTERIMPROVE. DEMOLISH, OR REPAIR ANY STRUC-
TURE. PRIOR TO RS 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 LI-
CENSE UW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SOO).)'
O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE K, WORAND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW 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 MENDED OR
OFFERED FOR SALE IF. HOWEVERTHE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION- THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEL
CO LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
CENSE UW DOES NOTAPPLY TO AN OW NE R OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICCNSED PURSUANT TO THE CONTRAC-
TORS
Ur
ENSE LAW).
O 1 AM EXEMPT UNDER SEC. B. 6 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 70001 OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE. AND
UY LICENSE M IN FULL FORCE AND EFFECT. /
LICENSE CLASS
G— 39 LIC. NO. % 7 63/
DATE b12 -' O I CONTRACTOR r..O , Jed OFf IN6
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM LNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COM PEN SAT ION INSURANCE, AS REWIRED BY 5ECTION
Q 7700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMDER ARE:
� GARNER
POLICY NUMBER
(M1eSSECRCN NEED NOT BE OCKNIETEDOF TOE PERMTISFORCNE VAINDRED OCUARS 3100)OALM
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUEUECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
COOE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
1
DATE: APPLICANT.
1
j WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL. AND SHALLBE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS IS IW.OW). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
F
SECTION 3708 OF THE LABOR CODE. INTEREST, ANDATTORNEYS FEES.
J CONSTRUCTION LENDING AGENCY
IHEREBYAFFIRM UNDER PENALTY OF VTTHEREIS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORKK FOR FOR WHICHICH THIS PERMIT IS ISSUED (SEC. 3091- CIV. C.).
1
LENDER'S NAME
LEM)ERSADCRESS
1 CERTIFY THAT 1 HAVE READ THISAPPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTYTO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
�N�is �1us�a�mAN
PERMITTEE NAME (PRINT)
g
0 i 13ATURE OF PERMITT EE DATE
C
PRESS
FIRM Y
APPLICATION O PERMIT L&
P/C
DATE NUMBER
M
ISSUE PE
OCC
DATE L/ CONST.
GROUP
ZONING SETBACKS
FRONT RW
❑
REAR
❑
SIDE/SIDE STREET RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTIONtO.F FACTOR PSF
ADJ. AREANALUATION
SFPJADD/REM
Garage/Carport
WPatio(Deck
u
Poovspa
ZRe
-Roof S -�
Commercial
m
'aluation ADJ.AREA
OU ITY DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANIC L�
INSPECTION FEE
ISSUANCE
SMTP
ENERGY P! y:
ENERGY P --
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
( �(�•
�•
COMMENTS
V
RECPT. NO. _V PAID BY
VALIDATION
WHITE—Department Copy. YELLOW—Finance Copy, PINK—Assessor L,opy. uvwcnnvu—rlln vy. .. ,y
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CET'; OF DIAIACk'D B,'"j.R
II` S ---EC -10!,! R E COR
W) .. - - . -, __
14�1 =r�rclj:j
SET BACK
FTGS/FOR%',S/STEEL
FLOOR JOIST
i FHA REG"ITS
ELECTRIC GROUND
GROUND PLUMBING
SLAB GRADE
TEMP POWER
I j UNDER FLOOR DUCT
l I UNDER FLOOR C0.'JDLJIT
FIREPLACE FOUNDATIor,.,
FIREPLACE BOND BEAM,
WATER SERVICE
ROOF SHEATHING
FRANIIINGVENTILIATION
ROOF COVER
ROUGH HEATING
MiD HT. POND BEAM,
83 FT. 130,',!D BEAT!--
FINAL DONID BEAM.
PR-,-GPIfD!rjG
I I BENCHING
ROUGH ELECTRIC
ROUGH GRADING
I i_FINIISH GRADING
ROUGH PLUMBING
SHOWERITUB TEST
(30L ELEETRIC
EXT. LATH;'SIDING
POOL FENCING
WALL INSULATION
CEILING INSULATION
OFF SITE IMPS.
DRYWALL NAILING
DEDICATIONS
SEWER
FINAL ENG.
SEPTIC TANK
LANDSCAPE/IRRIG.
SEEP PIT/L.L.
ON SITE Irl,.PS.
GAS AIR TEST
JFINAL ZONING
FINAL CONST, FIRE DEPT. FINAL
FINAL HEATING (( zEALTI DEPT. FINAL
FINAL ELECTRIC
FEES PAID
FINAL PLUMBING
_]_!_DEV.
I I I ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/LI SIZE
