HomeMy WebLinkAboutPR12-193}I
0
4
LL
0
coc
a
O
Lu
in
Lu
w
cri
Co
0
.]D4355Ttr
AnnRe55
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
. 21810 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION
L
apsa 8_ ! I j y6L`D'L I Z� TRACT f� U
OWNER 7" v
/
ADDRESS
CITY zIP
APPLICANT . yw . TEL
TEL.G D sC 'L . i-L.,�.
ADDRESS
CITY
ARCH/ENG/ ZIP TEL.
DESIGNER I�
ADDRESS
CITY PnSL..A, :,
OWNER -BUILDER DECLARATION
W I HEREFOR THE BY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS CENSELAWWHICH E FOLLOWING
OLLO INGR 70�(SEC. 7o3L.5BUSINESSANDPROFESSIONS
LM
iy( TURE, PRIOR TO ITS ISSUANCE, ALSO A NSRE lCl ALTER IMPROVE. pEMOLI CCOE AHY CIry OR
STATEMENT THAT HE OR SHE IS UCENsp➢URSU TOL1i1 RDVlB6gy5 STAUC-
p R IT TO FILE SIGNED
O CFSSI LAW (CHAPTER P (COMMENCING WITH SECTION 7000) OF DIVISION 3 OFTHE BUSINESS
FESSIpNS COOE)OR THAT HE OR SHEIS EXEMPT THEREFROM µp THE BASIS FOR THE COAND pa
NTRACTORS U.
[) TICN.ANYVK7TY OF OF SECTION 7W1.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS 7HfAPPI CANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED 0 HELEBFL7 ENT To
❑I,A90WNEROFTHE PROPERTY, OR MY EMPLOYEESIS ISNAG-E
Z WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR O FEREDS AS TFOR SOLE SALE (SEC 7A4iADual.
Ln NESSAND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN D
PROPERTH HIS Y WHO BUILDS R IMPROVESL.OYEHEREON, µp WHO DOES SUCH WOAKHIMSELFOR HERSELF OR
OFFER DFORrA HER OWN EMPLOYEES, PADV OFO WNLFOF
OFFERER FORS I THATSUCH IMPROVEMENTS ARE NOTINTENOFip OR
ALE, IF, HOWEVER THEBUILpING OR lMPAOVEMENT IS SOLD WlrHIN ONEYEAR OFCOMPLE
FMPROVE FOR THEE PURPOSEOF ALEIE THE BURG)=AF OF PAOVINtl THAT HE OR SHE plb NOT BUI1D OR
LLI ❑STRUCT) OF7HEPRDPTiRFy, AM EXCLUSIVELY CONE
Q 70 CONSTRUCT) PROJECr (SEC. 7041, EXCLU IV AND PROFESSIONS
WHO CONTRACTS
NTRACTS NOSUCH TO OWNER OFA PROPERTY WHOBUIlD56gIMPRECONTRACIORS U.
WLICENSED CONTRACTORS
ENSE LA DOES FOR SUCHPTO1E OWNS }{ FAPR CODE• T}LE CONTRAC70AB LF-
TORS LICENSE LAW.). RACTOA(S)LICENSEO pURSUANFTO THE CONTRAC.
O I AM EXEMPT UNDER SEC.
� 8. A P.C: FR TH1S RE,ISp}F
ODATE OWNER
LICENSED CONTRACTORS DEC
—
I I HEREBYN%- UNDER PENALTY OF PERJURY N 3 OIAM LICENSED UNDER PROVISfONS OF CHAPTER
P [COMMENCING WITH SECTION 7ppp) OF p}y}I$EOT AT I M LICENSED UNDER
"RO VI SIGNS CODE, CHAPTER
AF1' LICENSE k4. FULL FORCE AND � EFFECT.
F— xCENSE CLA98 // _
WATEL� LIC.NO. L=! ��3 -
/ r CONTRAG7CR n.�
WORKERS' COMPENSATION DECLARATION
I HERtBYAFFIRM UNDER PENALTY OF pEAJURV ONE OF THE FOLLOWING DECLARATIONS:
V]
I HAVE AND WILL
—�
MAINTAINACEFFTfp.
COMPENSATIONE OF CONSENT TO SELF -INSURE FOR WOAKERS'
OF THE WORK Fp, q AS PAUVIDED BYSECTICN 3?W OF. THE LABOR CODE- FOR THE PERFORMANCE
Q WHICH THIS PERMIT IS ISSUED.
—1HAVE AND WILL MAINTAIN WORKERS'COMPENSATICNy INSURANCE, AS REQUIRED BY SECTFON
3100 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUFiD, MY WORICEFiS' CCOOMPENSATION INSURANCE CARRIER µ0 POLICY NUMBER ARE:
CARRIER fX /
x i i 17 e
PCUCYNUMSER I
Lp (THISSEMMULEDNOT BEOMu-FEDOFTHE PERM"'IFORONf
I CERTIFY THAT IN THE PERFO µ � AR?(t1p6}OpLEES1
SHALL NOT IN
ANY PERSON INANY MANNFTHE ER BOAS TO BECOME SUBJECT TO ISSUED I
RK FOR WHICH THIS PERMIT IS
WORKERS'COMPENSATION LAWS OF =3 SUSU�CODE, I SH THE WORKFORTHWITH COMPENSATION PROV AND AGREE S THAT
TLOF 37Cq SHOUECOME
LD
LABOR
CODE. L SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
OS.OF
Q DATE;
lt.F ----� APPLICANT,
JL: SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIIL FW VERA TO ONE HUNDRED THOUSAND
DOLLARS (tt[ll,upp RAGEI5 UNLAWFUL. µOSHILL BE
1 IN ADDITION TO THE COST OF ODMPENSATION, DAMAGES AS PAONDEO USA1N
SECTION OF THE LABOR CONE, INTEREST, µD ATTORNEr3 FEES.
4
4 p CONSTRUCTION LENDING AGENCY
FOR THE ERFOFUNOER PENALTY OF pER1UAY THAT THERE ISA
FOR THE PERFORMANCE OF THE WORK FFU WHICHTHIS PE IS A CIS ISSUED(SEC. LEN0S7. CiVLENDING
AG
LJ.i CONSTRUCTION LENDING AGENCY
LENDER'SNAME
F-' LENDER'5ADDRESS
I GR7IFY THAT HAVE READ THIS APPLICATION µO STATETHAT 7HEABOVE WFOAMATppl9 CO
CONS7AUC7ION, ANDH q BYAmµaCOUNfV ORDINANCES AND STATE LAWSRELATING TO FORRECT,
Z ABOVE-MENTK)NED PROPERTY FOR NIZE REPRESENTATIVES PURPOSES. OF THIS COLTNTER CORRECT,
4 RPOSES. LAWS R LA71NG o BUiL E
=> M PERMIrTEE � NAME: (pplNr}
[!) IGNArURE OF PER FE /
2
AT
PRESS
FIRMLY
APP1_ICASI� P�RMI'C ��� h
DAi� ?UMBER\+� � ISSUE # 1FSC a_ k .
DATE + ti -a TYPE OC—-`'°(:
i CONS7
GROUP
ZONING SETBACKS
FRONT
REAR RW ❑
SIDE/SIDE STREET �� AW ❑ ~~ SIDE ❑ —�
PROPOSED USE t ~
NO. DWEL. �.y 7 I
UNITS NO.
STORIES/ NO.
BEDROOMS _ J
DESCRIPTION en rT
PaIIO/Deck
Poouspa
Re -ROOF
COMMerclM
Valuation
QUANTITY OESCRIP170N
FEE
M
CONSTRUCTION
PLAN REVIEW
ELECTRIC
S� ,
PLUMBING
Imo_
MECHANICAL
INSPECTION FEE
*yam
ISSUANCE
SMIP
1
ENERGY P/C
ENERGY PERMIT
s t
RETENTION FEE:
PRE-ALT FEE!
} ��
TOTAL FEES It„ It,,, ek=�
COMMENTS
^�
RECPT No.
Copy,
PAID 8Y
VALIDATION