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HomeMy WebLinkAbout16305 (20) ���'�'��� �� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � `'� _ 21660 E.Copley Drive Suite 190 ���--�G��� „vw (909)860-3195 Fax(909)861-3117 �� PRESS H�" BTJII.DING�'EI�MIT APPLICATION FIRMLY a ADDREE � � � �� APPLICATION � �� PERMIT � P/C o DATE NUMBER # � ISSUE 11) TYPE OCC �APN LOT TRA T. DATE '�r�l CONST. GROUP p OWNER p ADDR ZONING SETBACKS � CITY � 'j��; t FRONT RW ❑ APPUCAN TEL. REAR p SIDE/SIDE STREET RW ❑ � CONTAACTOR SlDE ❑ � ADDRESS PROPOSEDUSE ��"r`'� �� ��-"��t�� R-�'1%�� o CI7Y ZIP TEL. ..r� a� wo ARCH/ENG/ zW DESIGNER NO.DWEL. NO. NO. n. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. cr� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER�ECLAHATION SFRlADDlREM O I HEREBY AfFlRM UNDER PENQTY OF PERIURY 7FLV71 AM E%EMPT FROM THE CON7RACTORS LI- GBfBgB/C21pOR W CENSELAWFORTHEFOLIOWINGflEA30N(SEC.7031.58USINESSANDPROFESSIONSCADE:AN7CITVOfl (� C.7 ppUNTY'NHIpIREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROYE,DEMOL15H2ORHEPAIRANVSTAUG W NRE,PRqR TO ITS ISSUANCE,AL50 RE�UIRES 7HE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED W PaiiO/DeCk STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L6 � CENSEUW(CHAPTER9(COMMENCINGWITHSECT�ON7000)OF�fVISION90FTHE8USWESSAN�PRO� � POOUSpe FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEOEOEXEMP• (� TION.ANVVbIATIdJOFSECT10N7031.68YANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � AqVILPENALTY OF NOT MORE THAN FIVE HUNORED DOLURS(f500).�: � �I,ASOWNEROFTHEPROPERTY,ORMVEMPIOYEESWITNWAGESASTHEIR60LECOMPENSA7iON, 0 COR1me�Ci81 � WILL DO iHE WORN,ANO THE S7RUC7URE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7o4t,B1J51� J � NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENBE LAW DOES NOT APPLV TO AN OWNER OF = PROPER7Y1NF10 BUILOS OR IMPROYES TMEREON,AND WHO DOES SUCH WOFiK HIMSELF OR HERSELF OR (L T17ROUGH HIS OR NER OWN EMPLOVEES,PFOVIDED TMATSUCM IMPROVEh1ENT5 ARE NOT MTENDED OR m QOFFEREOFORSALEIF,HOYYEVERTMEBUIl01NGOHIMPflOYEMENTI5501DWITHINONEYEAROFCOMP�E- � TION,THE ONMEH�BUI/AER WILL HAYE THE BURDEN OF PROVIN6 THAT HE OR SHF DID NOT BUILA OR = IMPROVEFORTHEPURPOSEOFSILLE). W ❑I.ASOVMEROF(HEPROPEHTV,AAIEXCLUSIVELYCONTRACTINC,WRHLICENSEDCONTRACTORS � TO CONSTRUCT TNE pROJECT(SEC.�041,BUSINESS ANO PqOFESSIONS COOE:THE CONTRACTORS LI- Vfl�U8li0f1 ADJ.AREA W CENSELAWDOE5NOTAPPLYTOANONMEROFAPROPERTVWHOBUIIDSORiF1PROVESTHSREON,AND ---.— Z Nh1000NTMCTSFOR�UCHPqOJECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE F� TORS IJCENSE UW.�. �� ❑I AM E%EMPT UNDER SEC. B.8 P.C.FOR Th115 REASON Q U u. � DATE � OWNER U 0 W f,, LICENSED CONTRACTORS DECLARATION w � I HEREBV AFFIRM UNDER PENAL7Y OF PERJqRV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER d � �( °� d Y(COMMENCINO WRFI SECTION 7000)OF DIYISION 30F THE BUSINESS AND PROFESSIONS CXJDE,ANO Z '����g l. � ��CC �L7(pL • � X MY UCENSE IS IN FULL FORCE ANO EFFECT. � ��� � ���..- �,, �� �� L1J � LICEN5E CLASS� __ LIC.NO. j � J V DATE _ CONTRACTOR d W � WORKERS'COMPENSATION DECLARATIQN ¢ � IHEREHYAFFIpMUNOERPENALTVOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z O IHAVEANDWILLMAMTNNACERTIFICATEOFCONSENTTOSELF-INSUREFOAWORKERS' 2 —_ C01Af+ENSATION.ASPROVIOEUBYSECT10N31000F7HElABOFCODE,FOR4HEPERFORMANCE U �t OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO. � � � �I NAVE/VdD WILL MAINTAIN WORKERS'COMPENSATION INSUHANCE,AS RE4UIRE�BV SECTqN Q 37000FTHELAEQACODE.FORTHEPERFORMANCEOF7HEWORKFORWHICHTHISPERMITIS ISSUED.MY WORKERS'COMPENSATION WSURANCE CARRIERAND POLICY NUMBERAflF� CONSTRUCTION __ jcnaA�ER__ PLAN REVIEW _ Z va��cvrtuMeEA _._____ — ELECTRIC ¢ � , 0 (IHI55ECTKXdNE�N078£Wh1PlEiEDOFTFfPEfW7TI5WRONEHl1NDFlEDIX%1Ai15(E1ao�OFiLESS�. PLU o�rµa..r�,� .. TK .yS. � I CERT;I-Y THAT N THE PERFORMANCE OF THE N10RK FOR WHICH THIS PERMIT IS ISSUE�,I ME ANICAL T (!j SMAlLNOT EMpLOYANY PERSCN IN ANY IAANNER SO AS TO 6ECOME SUBJECT TO THE y WORKERS'COMPENSATION IAWS OF CPLIFORN10.AND AGREE THAT IF I SHOULO BECAME INS ECTIOI�� S SUBJECi TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LABOR — �L�1 WDE,I SHALL FOflTHWITH COMPLV Wihl THOSE PROVISIONS. �SS ANCE ��� � SMI p DATE: FPPLICANT: � J WARNING:FAILURE TO SECURE WORKERS'COMVENSATION[bVERAGE IS UNLAWNL,AN�SHALL BE EN - �'*�^�^+..'•-rc-.._.... - �y SUBJECTANEMPLOVEHTOCRIMINALPENALTIESANDCM�FINESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT OOLLARS(5�00.000).IN AODIT�ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37oeOFTHELA80RCODE,INTEREST,ANDATTORNEVSFEES. RETENTIONFEE: n�. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEHEBYAFFIRMUNOERPENALTVOFPERJURYTHATTHEiiEISACONSTRUCTIONLEN�WGAGENCY _ FOR TNE PERFORMANCE OF 7FIE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV C.�. Z W � LENDER'S NAME — F IENDER'SAD� SS � � TOTAL FEES ¢ I CERTIFV TH I H E READ THIS APPLICATION ANO 5 TE THATTHE ABOVE INFORMATION IS CORRECT. W I AGREE TO MP NATH ALL CITY AND COUNTY OR ANCES 0.ND STATE lAWS PEI.ATING TO BUILDING � � CANSTRUC ION. DHEPEBYAUTHORREREPRES TIVESOFTHISCOUNTVTOENTEflUDONTHE - � .ABOVEME iqN D PROPER7V FOP INSPECTION P a sEs. COMMENTS � �°' J � m E tTTEE NT Q � N � SIG TUR OF PER ITTE = RECPT.NO. PAI�BY VALIDATION ~ WHITE—Department Capy,YELLOW—finance Copy,PINK—Assessor Copy,GOIDENROD—File Copy,GAEEN—Appli Ys Copy . . .i.. �n� -.l-, n :�:'.� .� ..s... . .,.:.v� ; :.,�rt:" ,. � ., ,.� ,. . 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