HomeMy WebLinkAbout11400 (5)CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT or
.. ¢ 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS
APN LOT TRACT
OWNER
ADDRE S O
CITY Y1010 454IP17
ACTEL
APPLICANT ✓ TEL.V51,60 00'77
CONTRACTOR - ' s S71, ad
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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. 7031.5 BUSINESS AND PROFESSIONS CODE ANY CITYQR
COUNTY WHICH REQUIRES APERMITTO CONSTRUCT, ALTER. IMPROVE. DEMOLISH, OR REPAIR ANY STRUC-
TURE, 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 a (COMMENCING WITH SECTION 70001 OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VKXATION OF SECTION 7031.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
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 (SEG 7044• BUSH
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHOBUILDS 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 FOR SALE IF, HOWEVER THE BUILDINGOR IMPROVEMENT IS SOLD WITHINCNE YEAR OFCOLIPLE-
TION, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
G L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
CENSE UAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
VAio CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC.
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION TOM) OF DIVISION 3OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS e -ZD LIC. NO. "KA/ MM�
DATE 11–SZ' — 2UpCONTRACTOR�+�.r
WORKERS' COMPENSATION DECLARATION ' (i✓ pi
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS. ✓ 4c'
—1 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
OETHE WORK FOR WHICHTHIS PERMIT IS ISSUED.
L.
_ I HAVE ANO WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIRED aY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER �Y- t1(
POLICY NUMBER In, 2 -
(THIS SECTION NEEDNOT BE COMPLETEDOFTHE PERMITS FOR ONE HUNDRED Mul (5100)OR LESS}
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, SHALL THWITH COMPLY WIJ�'3'i�S d NS. ^
DATE: APPLICANT E" V4 ��
WARNING: FAILURE TO SECURE WORKERS'COMPENSAT COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND
DOLLARS (5100,000), N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3087, CIV. C.).
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHATTHE 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-MENTION/EDD PROPERTY
FOR INSPECTION PURPOSES. A
PER NA PRINT
IV
SIGNATURE OF PERM
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�— PRESS
FIRMLY
APPLICATION
PERMIT
, PIC
DATE r
NUMBERV
V #
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
REAR
SIDEISIDE STREET
RW C
SIDE
0
PROPOSED USE
NO. DWEL. NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION - SO. FT.
FACTOR PSF ADJ. AREA/VALUATION
SFRIADD/REM '
Garage/Carport
Patic/Derk
LWLI
LL
PooVSpa
Z
Re -Roof
Commercial
Valuation
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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W
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Q
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
ME6 A
INSPECTION FEE
ISSUANCE
$-
r
5
SMIP
ENERGY P/C
�N
ENERGY PERMIT BAR
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
lu
COMMENTS
RECPT. NO. PAID BY
VALIDATIO +
"mi I c—vepertmeni Dopy, TL:LLuw—mnance Uopy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
VMS ki WE;
SET BACK
CITY OF DIAMOND BAR
INSPECTION RECORD
FLOOR JOIST
FTGS/FORMS/STEEL
FHA REQMTS
ELECTRIC GROUND
UNDERFLOOR DUCT
GROUND PLUMBING
UNDER FLOOR CONDUIT
SLAB GRADE
FIREPLAbE FOUNDAYION
TEMP POWER
FIREPLACE BOND BEAM -
WATER SERVICE
MID HT. BOND BEAM
ROOF SHEATHING
8 FT. BOND 13EAM
FRAMINGIVENTILIATION
FINAL BOND BEAM
ROOF COVER
PRE-GRADING
ROUGH ijig
BENCHING
ROUGH ELECTRIC
ROUGH GRADING
ROUGH PLUMBING I
FINISH GRADING
SHOWER/TUB.-TEST
POOL ELECTRIC
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.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
SEPTIC TANK SIZE
SEEP PIT/LI SIZE