HomeMy WebLinkAbout17009CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21825 E. Copley Drive
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS $ 2 /D b
APN LOTTRACT
OWNER _
ADDRESS
CITY TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CIN ZIP TEL
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOWING REASON (SEC. T031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESAPERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRIIC.
TURF_ PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L6
CENSE UW (CHAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS
RP
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 70]1.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
O L AS OWNER OF 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 CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTYWHO 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 FORSALE. IF, HOWEVER, THE BUILDING OR MPROVEMENT IS SOLD WITHIN ONEYEAR OFCOMPLE-
TION, THE OWNER'BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE
FOR THE PURPOSE OF SALE}
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 U -
CENSE LAW DOES NOTAPPLYTOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS W1THACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
O I AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
(COMMENCING WITH SECTION 70001 OF DIVISION 0 OF THE BUSINESS AND PROFESSIONS COOE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO. /
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER 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 S700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
57000E THE LABOR CODF_ FOR THE PERFORMANCE OF THE WORIFICH
THIS PERMIT IS
ISSUED. MY WORKERS COMPE' ATI INS RAN RERANDUMBERARE
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE OOM P ETEDOFTIE PERMTIS FCRONEHNDREDOOLIMLS(S100)On LEM
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER BOAS TO BECOME SUBJECTTO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS COMPENSATION PROVISIONS OF SECTION GOOF TH LABOR
CODE, I SHALL FOFrrH�WITH COMPLY WITH THO RONSIONS.
DATE: yJ "'!/-0 '-APPLICANT.
II
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COYERAG UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP ONE HUNDRED THOUSAND
DOLLARS (111100.003). N ADDITION TO THE COST OF COMPENSATION, AMAGES AS PROVIDED FOR IN
I SECTION 070B OF THE LABOR CODE. INTEREST, ANDATTORNEY'S FEES.
1 CONSTRUCTION LENDING AGENCY
i
I HEREBYAFFIRM UNDER PENALTY OF FDA
THAT THERE IS A CONSISION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORNK TOR WHICH THIS PERMIT IS ISSUEDUED (SEC. 3097, CIV. C.G.
i
LENDERS NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE 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 COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
i
PERUrTTEE NA WIT) 1
O SIGNATURE OF EE DA E
EXPIRED
JUN 18 2002 PRESS
FIRMLY
PERMIT I_
23 I
DATEAPPLICATION
x�
NUMBER
✓2
ISSUE /� TYPE CC
DATE J v CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR 13-
SIDE/SIDE STREET
SIDE/SIDESTREET RW 0
SIDE ❑
PROPOSED USE
NO. DWEL. IKO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION
SFRJADD/REM
CD
Garage/Carport
WPatio/Dock
LL
POOVSPa
0
Z
Re -Roof
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
Cr
F–
U
W
J
W
C.7
Z
m
J
a
ZU_
4
S
U
W
7,
CONSTRUCTION V
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE`, _
ISSUANCE T �U
SMIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES l 3i 70
COMMENTS
I
RECPT NO. PAID BY VALIDATION
WHITE—DApanment Copy. YELLOW—Finance Copy, PINK—Assessor Loopy, LavwtNHUL�rIK1 wpy, U"=N—APPncanc 5 a Py
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CITY OF DIAMOND BAR
INSPECTION RECORD
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SETBACK!
FLOOR JOIST l '
FTGS/FORMS/STEEL
FHA REOMTS
ELECTRIC GROUND ;
UNDER FLOOR. DUCT,
GROUND PLUMBING
ONDUIT.
UNDER FLOOR CONDUIT.-
SLAB GRADE
SLAB
FIREPLACE•FOUNDATION -
TEMP POWER I
FIREPLACE BOND BEAM
WATER SERVICE i
MID HT BOND BEAM
ROOF SHEATHING'
8 FT. BOND BEAM `
FRAMINGNENTIL IATION
FINAL BOND BEAM
ROOF COVER
PRE -GRADING !
ROUGH HEATING
BENCHING
ROUGH ELECTRIC
ROUGH GRADING ---
ROUGH PLUMBING
FINISH GRADING j
SHOWER/TUB TEST
POOL ELECTRIC
EXT LATH/SIDING
POOL FENCING
WALL INSULATION
r - I POOL FINAL I
CEILING INSULATION I
OFF SITE IMPS.
DRYWALL NAILING
DEDICATIONS
SEWER
FINAL ENG.
SEPTIC TANK !
i LANDSCAPE/IRRIG.
SEEP PIT/L.L. (
i ON SITE IMPS.
GAS AIR TEST j
! FINAL ZONING
FINAL CONST. I
: ' FIRE DEPT. FINAL
FINAL HEATING I I
HEALTH DEPT. FINAL !
FINAL ELECTRIC
1 I DEV. FEES PAID
FINAL PLUMBING
1 ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PITIU SIZE
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