HomeMy WebLinkAbout18177 (17)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21825 E. Copley Drive
(909) 860-3195 Fax (909) 861-3117
"- BUILDING PERMIT APPLICATION
ADDREE 1
ADDRESS V
APN LOT
OWNER
ADDRESS
CITY ZIP TEL r
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FRCM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRES A PERMITTO CONSTRUCT. ALTER IMPROVE. DEMGUSR CR REPAIRANYSTRUC.
TUBE. 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 LAW (CHAPTER 9 (COMMENCING WITH SECTION 7DOO) OF DIVISION S OF THE BUSINESS AND PRO•
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3500)):
D I. AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL M
DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 74. BUST•
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORKHIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE.
TION. THE OWNER'BUILDER WILL HAVE THE BURDEN OF PROVISO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
E7 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 NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
T4
10 CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CCNTRAC.
TORS LICENSE LAW.). '
O IAM EXEMPT UNDER SEC. B. L P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
B (COMMENCING WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FOR AND EFFECT.
LICENSE CUSS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM LINDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WAL MMNTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY 5ECTION 77DO OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
a7000FTHELABOR E, FORTHEPERFORM CE OF THE FOR YYFIICH THIS PERMIT IS
ISSUED. MY WORKER' PEN IN CE CARRI O POLICY NUMBER ARE:
CARRIER
POLICY NUMBER 0
(DOSsEcnoN NEEDNOTSE CC PLETEDOFTHE PEiMTIS FORONE RUNDACDCOLLARS($100)ORLESS).
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT 70THE
WORKERS'COMPENSATION LAWS OF CALIF NI 0 AGREE THAT IF I SHOULD BECOME
SUBJECT THE RKERS'COMPENSAT PROVISIONS OF SE CT 77000E THE LABOR
E,I ALLF TH�JWITH� COMPLY WI OSE VISIOFIS.
DATE: PLIC -ANT.
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UM.AWFUL,AN� ALLBE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CMLFIN ES UP TO ONE HUNDRED TH SAND
DOLLARS'$IDD.000), IN TO
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
5EC71O N 5705 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC. 3097, CIV. O).
LENDERS NAME
LENDERSADORESS
1 CERTIFY THAT IHAVE READ THIS APPLICATION 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 CF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERMITTEE
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SIGNATURE OF PERMITTEE i DATE
PRESS
FIRMLY
APPLICATION / PERMIT
DATE K� NUMBER
P/C O �1
#
ISSUE TYPE'
,
/ OCC
DATE CONST.�_L/
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDESTREET
RW
❑
SIDE
❑
PROPOSED USE 10
LA
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NO. DWEL. NO.
0, Ai
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF
ADJ. AREANALUATION
SFR(ADD/REM
CD
Garage/Carport
WPatio/Dock
U-
PooVSpa
0
Z
Re -Roof
OJ
Commercial
5
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION
FEE
J
Q
U
F—
U
W
J
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L7
2
a
a
U
Z
a
2
U
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CONSTRUCTION II /r
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
Su
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: T S
PRE -ALT FEE:
TOTAL FEES �j
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COMMENTS* ,
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9 0 rp
on 44
RECPT. NO. PAID BY
VAUDATION
WHITE—Departrfient Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENHOD—File Copy, GREEN—Applicant's Copy
CITY OF DIAMOND BAR
Ii ISPEC i 10N'REC0R0
11
SET BACK
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c);f'li'(+;.a�:�` (c) T �1�k6: (►��-' :� e'�e�
FLOOR�IST,
FTGS/FORMS!STEEL
I FHA REOMTS
ELECTRIC GROUND
; UNDER FLOOR DUCT
GROUND PLUMBING
UNDER FLOOR CONDUIT _
SLAB GRADE
FIREPLACE FbUTIbATION
TEMP POWER
FIREPLf;CB BOND BEAM
WATER SERVICE
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MID HT. BOND BEAM �
ROOFSHEATHING
8 FT. BOND b Af .
FRAMING/VENTILIATION
FINAL BOND BEAM
ROOFCOVER
i PRE -GRADING
ROUGH HEATING
BENCHING
ROUGH ELECTRIC
ROUGH GRADING
ROUGH PLUMBING
FINISH GRADING _
SHOWERITUB TEST
POOL ELECTRIC
_
EXT. LATH/SIDING
j
POOL FENCING _
WALL INSULATION
POOL FINAL
I
CEILING INSULATION
OFF SITE IMPS.
DRYWALL NAILING
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DEDICATIONS
SEWER
FINAL ENG.
SEPTIC TANK
LANDSCAPE/IRRIG.
_
SEEP PIT/L.L.
ON SITE IMPS.
GAS AIR TEST
FINAL ZONING
FINAL CONST.
FIRE DEPT. FINAL
FINAL HEATING
HEALTH DEPT. FINAL
FINAL ELECTRIC
DEV. FEES PAID
FINAL PLUMBING
ENERGY
COMMENTS
a���1r<��.
SEPTIC TANK SIZE
SEEP PITIU SIZE
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