HomeMy WebLinkAbout13382 _ 1f� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
� 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 �RESS
���'TM' BUILDING PERMIT APPLICATION FIRMLY
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c� ISSUE / /� TYPE OCC
APN LOT T CT DATE ?����`9 CONST. GROUP
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Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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Q I HEREBY AFFlRM UNDER PENALTY OF PERNRY THAT I AM EXEMPT FROM THE COMRACTORS LI- G8f996/CflIpOfl
W CENSEI.AWFORTNEFOLLOWiNOREASON(SEC.7031.5BUSINESSANDPROFESSbNSCODE:ANYCI7YOR (n
U COUHTYWHIpIREWIRESAPERMfiTOCONSTRUCT,ALTER,IMPpOVE,DEMOLISH,ORREPAIRPNYSTRUC-
w TURE,PRIOR TO RS ISSUANCE.ALSO REWIRES THE APPLICAHT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
STATEMEHf THAT HE OR SHE IS 110EN5E0 PURSUANf TO 7HE PROVISIONS OF 7HE CONTRAC70R5 LI�
� CENSE UW(RUPTER Y(COMMENCINO Wlhl SECTqN 7000)OF DIVISION]OF THE BUSINESS AND PRO- � PooVSpa
FESSqNS COOE)OR THAT HE OR SHE IS EXEMPT hiEREFROM AND THE BASIS FOR THE ALLEGED EXEMP•
TION.ANVVIOLATIONOFSECTIOH70.71.6BYANYAPPLICANTFORAPERMITSUBIECTSTHEAPPLICANTTO Z Re-Roof
� A CINL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(5500).):�
� ❑I,ASOWNEROFTHEPROPER7Y,ORMYEMPLOYEESWITHWAGESAShIEIRSOLECAMPENSATION, � 0 COR1fI1BfCl81 � �
WILL DO THE WOPoC AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70u,BUSI- J
NESS AHD PROFESSIONS CODE:THE CON�HACTORS LICENSE UW DOES NO7 APPLV TO AN OWNER OF
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Q THNOUGH HIS OR HER OVM E�IPIOYEES,VROVIDED THAT SUCH IMPROVEMEMS ARE NOT INTENDED OR m
0 ,OFFERmFORSALEIF,HOWEVERTMEBUILDINGOflIMPROVEMENTISSOLDN7THINONEVEAROFCOMPLE-
Z 'TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
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❑1,AS OWNER OF THE PROPEHfV,AM E%CLUSIVELY COHTRACTINO WfTM LICENSED COHTRACTORS
� TO CONSTRUCf THE PRQIECT(SEC.70H,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V91U811011 ADJ.AREA
W CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND
� NRIOCONTMCTSFOHSUqiPRQ1ECTSWITHACONTRACTOR(S)LICENSEDPURSUANT70THECONTRAG QUANTITY DESCRIPTION FEE �
� 70RS UCENSE UW.).
Q ❑1 AM IXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON �
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� UATE OWNER �
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�Q LICENSEDCONTRACTORSDECLARATION W • ---.�
CC I HEREBYAFFIRII UNDER PEN�LTY OF PERIURY THAT I AM LICENSED UNDER FROVISIONS OF CHAPTER � 1`j''"`�'
� 0(CqAMENCINO WITH SECTION 7000)OF ONISION 9 OF THE BUSINESS AND PROFESSIONS COOE,AND Z
��� IAY LICEHSE IS IN FULL FORCE AND EFFECL m
� LICENSE CLASS LIC.NO. j pA A V " � ����
� DATE CONTRACTOR a � I"'G� v
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� WORKERS'COMPENSATION DECLARATION � •""` " "` "-'- A �+
a SC'�YTTY a�+T�lt' ,�l�i� �tl�a �
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N I HEREBV AFFIRM UNDER PENILTV OF PERIURV ONE OF THE FOILAWING DECURATIONS: v��y•v - �
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� I HAVE AND WILL MAIN7AIH ACERfIFICATE OF CONSENT TO SELF-INSURE FOR WOHKERS' 2
� COMPENSATION,AS 7ROVIDED BY SECTON 37000F THE LABOF CODE,FOR THE PERFORMANCE W
OF TNE WORK FOR NMICH THIS PERMIT IS ISSUED. �
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w _I HAVE M1D WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS HEOUIRED BV SECTION
Q 370o OF THE LABOR CODE,FOR THE VERFORMANCE OF iHE WORK FOR WHICH THIS PERMI715 �b
� ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION I L
jc�RqiER PLAN REVIEW
� POLICV NUMBER ELECTRIC
0 �sEcnarr�wreEoo�.aFrmoFn�vEw.arsioaa+EM�moau�rs�siao)oa�ss} PLUMBING
Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
(�J SHALL NOT EMPLOY ANY PERSON�N ANY MMINER SO AS TO BECAME SU&IECT TO THE
N WORKERS'COMPENSATION LAWS OF CALIFOHN10.�1D AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SUBJECT TO THE WORKERS'COM7ENSATION PFOVISIONS OF SECTION 37000F THE LABOR
CADE,I SHALL FOR7HWI7H COMPLY WITH 7HOSE PROVISIONS. �SSUANCE �L)�Q��(
p DATE: APPLICANT: -SMIP • i 'i V
� ENERGY P/C
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
� SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
DOIURS(f100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN /�
� SECTION 37oE OF 7HE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. � RETENTION FEE: ��v
� CONSTRUCTION LENDING AGENCY P�-�LTi FEEti D O nA-
� I HEREBV AFFIRM UNDER PENALTV OF FERIUM T1AT THERE IS A CONSTRUCTION LENDING AGENCY (�/l.�^r�
FOR THE PERFORMANCE OF THE WORK FOR NM1iICH 7HI5 PERMIT IS ISSUED(SEC.3097,CIV.C.).
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� LENDER'SNAME - /'SD
H LENDER'SADDRESS �
w I CERTIFV THAT I HAVE READ THIS APPLICATION M1D STATE THAT THE ABOVE INFORMATION IS CORRECL TOTAL FEES � I
� 1 AGREE TO CAM7LV WITH�LL CT'AND COUNTY ORDINANCES AND STATE UWS RELATINO TO BUILDING
CONS7RUCTION,AND HEREBY AUTFIORIZE REPRESENTATIVES OF 7HIS COUN7V TO ENTER UPON THE
ZABOVE•MEHTIQ�IFDA.P80PERTYfOHINSPECT UHPOSES. � COMMENTS � ' �
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� SIONATURE O ERMITT DA7E `'
� RECPT.NO. . PPJD BY VALIDATION �
WHITE—DepeAment Copy,YELLOW—Finence Capy,PINK—Assessor Copy,GOLDENROa-File Copy,GREEN—Applicant's Copy
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SLAB GRADE FIRE AGE OI.�NDAT.ION.°�<��,�i i; , ...�;"` � ,'.+'�, ,-"`:,`-;.;
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FRAMINGNENTILIATION � � �� FINAL BOND.B�AM , , ., � ,..
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ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING "' FINISH GRADING
SHOWER/TUB TEST POOL ELECTRlC
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. �' �,' � ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FIfVAL CONST. �, o� �� FIRE QEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBING ENERGY
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