HomeMy WebLinkAbout15561 (22)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS
APN LOT TRACT
OWNER A3Sii Cr L
ADDRESS Z3 . 3 ,5_UM7
CITYf%�A�i✓/ ZIPy17b5__ TEL 6o -'S2 (-'I
APPLICANT rtEi6Lr6- TEL.
CONTRACTOR
ADDRESS
CRY ZIP TEL.
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7637.5 BUSINESS AND PROFESSIONS COOEANY CITYOR
COUNTY W4CH REOL)IRESA PERMITTOCCUSTRIICCALTER. IMPROVE, DEMOLISH, OR REPARANY STRUC•
TORE. PRIOR TO FTS LSSUANCE. 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 a (COMMENCING WITH SECTION TOGO) OF DIVISION S OF THE BUSINESS AND PRO•
FFSSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
TION, ANY VIOLATION OF SECTION 7641.5 BYANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL. PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (]500).);
0 LAS 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. 70". S USI -
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR MPRWES THEREON, AND WH0 DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT NTENOED OR
OFFERED FOR SALE F, NOWEVEIL THE SULDNG OR IMPROVEMEMIS SOLD WITHIN ONE YEAR OF COMPLE-
TION. THE OWNER-0UILDER WILL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR
IMPFIOVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY, AIA EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 70M BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACT3 FOR SUCH PACUECTS WITH A OONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW).
O 1 AM EXEMPT UNDER SEC. B. S P.C. FOR THIS REASON
DATE ^ U d GONER
LICENSED CONTRACTORS DECLARAT�CINI
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCNO WITH SECTION TO00) OF DIVISION ] OF THE BUSINESS AND PROFESSIONS CODE, AND
MYLICENSE IS N FU -L FORCE AND EFFECT.
LICENSE CUSS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFaNSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 4700 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 REWIRED BY SECTION
4700 OFTHE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
SWED. MY WORKEFIS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
POLICY NUMBER
L (Dies SECTION NEED NOT BE OCM LETTDOFTE PERMIT IS FORCNE WCAM D0l1MS(L1O0) ORLC&%
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT TO TH ED. I
WORKS OT EMPLOY ANY PERSON WS IN OF CA MANNER AND S TOAGR BECOME SI BJECTSHOULD
B THE
j WORKERS' THE
AT*NWORKERS*
COMPENSATION
NIA.PRO VISIONS OF EE THAT
N3100 F BECOME
- SUBJECT TO THE WORKERS'COMPENSATION DROVISIONS OF SECTION ]7000F THE LABOR
OWE.1 SHALL FORTNVVITH COMPLY WITH THOSE PROVISIONS.
I
I DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL
SUeIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSAND
DOLLARS IS 100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
F SECTION 77050E THE LABOR CODE. INTEREST AND ATTORNEYS FEES.
1 CONSTRUCTION LENDING AGENCY
i
I HEREBYAFFIRMMANCE PENALTY OFK FORW TENTTHERE WSACONSTRUCTION LENONO AGENCY
FOR nit PERFORMARCE OF THE WORK FOR WHICH THIS PERM1715ISSUED (SEG ]OW, CIV. G).
3
LENDERS NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE 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
3 CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTA7IYES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
7 0 5oz"-G///6.7
PERMITTEE NAME PRINT) 7 _/r D�
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SIGNATURI:OFFERAWny DATE
M
PRESS
FIRMLY
APPLICATION _ PERMIT /55 P/C
DATE NUMBER 1 k
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR 13-
SIDE/SIDE
SIDE/SIDE STREET RW ❑
SIDE
PROPOSED USE
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM '
(n
Garage/Carport
WPatiG/Deck
LL
POCUSpa
ZRe
-Roof
0
Commercial -
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
_U
W
J
W
0
2
J
a
J
a
U
Z
a
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U
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CONSTRUCTION
PLAN REVIEW
-11
ELECTRIC[ --
PLUMBING_
MECHANICAL
INSPECTION FEE
ISSUANCE �� r r ►�F
SMTP�T-tNM
Ci'TtiU-Sr;rL
ENERGY P/C T
ENERGY PERMIT II
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES 7u
COMMENTS
AL
RECPT. NO. PAID BY VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy. PINK—A33e830r L 4PY, UULUn NhVL r %,Wy, U ... r -- PP -11 s —Py
CITY OF DIAMOND BAR
INSPECTION -RECORD
%t p
SET BACK
FLOOR JOIST.
FTGS/FORMS,'STEEL
FHA REQMTS
ELECTRIC GROUND
UNDER FLOOR DUCT
:GROUND PLUMBING
UNDER FLOOR CONDUIT
SLAB GRADE
FIREPLACE FOUNDATION
TEMP POWER
FIREPLACE BOND BEAM
WATER SERVICE
MID HT. BOND BEAM
ROOF SHEATHING
8 Fr. BOND BEAM
FRAMING/VENTILIATION
FINAL BOND BEAM
ROOF COVER
PRE -GRADING
ROUGH HEATING
BENCHING
ROUGH ELECTRIC
61
ROUGH GRADING
ROUGH PLUMBING
FINISH GRADING
�SHOWER,TUB TEST
POOL ELECTRIC
'EXT. LATH/SIDING
-WALL INSULATION
INSULATION
POOL FENCING
POOL FINAL
OFF SITE IMPS.
.'CEILING
.DRYWALL NAILING
DEDICATIONS
SEWER
FINAL ENG.
SEPTIC TANK
LANDSCAPE/IRRIG.
SEEP PIT/L.L.
_b
N SITE IMPS.
GAS AIR TEST
FINAL ZONING"
FINAL CONST.
FIRE DEPT, FINAL
FINAL HEATING
FINAL"ELECTRIODEV.
FI -NAL P LU%IB!N
¢
HEALTH DEPT. FINAL
FEES PAID
ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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