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HomeMy WebLinkAbout15437 - 21551 CARRISO RD• CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 4 (909)960-3195Faa(909)861-3117 PRESS ' BUILDING PERMIT "PLICA JOBSITE ADDRESS I>4.CA39&;S in ,Ab APN MOT T T OWNER z CITY /ZZIP TEL y3 APPLICANT TEL ADDRESS ZI Tr _ ARCWENG/ DESIGNER a ADDRESS ZIP TEL Lo -CITY La D OWNER-SUILDER DECLARATION IHEREBYAFFIRM UNDER PENALTY OF PEILAM TNT IAM EXEMPT FROM THE WHfPoICTQRS IF C"EtAWFORTEPOLLAWWP"SON(SEC70M.S UBWESSANDPROFESSOONSCODEANYCRYDR RUN(YYMMMEGLARMAPERIYYTOCON 7R=,,AL,TERS"(YWEDENOUSKORP PAMANYUMIC-- T1RE. PRIOR TO ITS ISBUANC . KSO REMIRES THE APPLICANT FOR S" PERMIT TAD- FILE ASIGNED STATEMENT TWR HE OR SHE B LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL CENSE LAN (CHAPTER. MOMMENOING WITH SECTION 7W" OF DIVBION S OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THEBASSIS FOR TEAL ALLEGED ANY HIOLAXIONOFSECMNTblt.SBYANYAPPLXA FORAPEiMITSUBJECTS THE APPLICANT TO AONL PENALTY OF NOT MORE THAN MEH HUNDRED DOLLARS ISSGP}k ❑ LASORNEROFTHE PROPERTY OR MY EMPLOYEES WITH WAGES ASTHEIR SOLE COMPENSATION, WILL SOTS WOOL AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR BILE (SEC. TOE•. BLBF N.—AO PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO ATOWNEROF PROPS TYMNOSLA DS OR WPROVF3TiEREOH, AND WHO DOE38UCH WORKFSMSELFOR HERSELFOR - THROUGH HIS ORHER OWN EMPLOYEES. PROVIDEDTM SUCH IMPFAOVEMEITSARE NOTNTENDFD OR OFFERMFORSALEIF.HOWEVERTHESURDNGOFt WF OVEMENTOSOMAWRWNONEYEAROFCOAARE- ' TIOK TK CWMU BLRDER WSJ. NWE THE ONA)M OF PAOYSD THAT HE OR NE DIG MOTBWI.D OR MPfOYE FOR 1HE PURPOSE UR SAL.EL OM ` flSTRUCTTEROFTIECT EISINEI ISER7Y,JMi CONTRACTORS CONSTRUCT THE PROJECT (SEQ 70M, RAIS./E53 AND PHOFESdOlB CODE THE OONiA,WCTORB LF IANDPNTRACTNGVCODE. THECONTRACTO DENSE LAN DOES NOTAPPLYTOAN OWNER OFAPROPERIY WHO SURDS OR MPRDVES THEREON. NO, WHOOMARACTS FOR SUONPROECTSWRNAOCNTRACT0RIS)LICENSED PINRUA TTOTE CONTRA' TORSUCENSEIANC} OIAMMIEIPTUIDERSEC.. .. _ B. PC- MR THIS REASON LL DATE .OWNER .. .. LICENSED CONTRACTORS DECLARATM . I HEREBY AFFIRM WOO PENALTY OF KRAJRYTHAT IAN LICENSED UNDER PROVISIONS OF WAPTER -. SMOMMENONG WITH SECTION TMW OF DIVISION a OF THE BUSNESBAM PROFESSIONS OWE. NO L� MY LICENSE IS* FULL FORCE AND EFFECT. LICE" DATE CONTRACTOR N WORKERS' COMPENSATION DECLARATION .. I HEREBY AFFIRM UNDER PENM.TY OF PERiY ONE OFTHE FOLLOWING ARATICNS: TJPERJURY� 401 NAVE AND WI.LMANTANA CERTIFICATE OF COMM TD SELFNIBURE FOR WORMS' - _I OO►MBIBATION, AS PROVIDED BY SECTION 3M OF THE LABOR CODE, FOR THE PERFORMANCE OFTE WOW FOR W RICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WOHCERBCOMPENSATION INSURANCE AS REQUIRED BY SECTION WWOFTHE LABOR CODE, FORTE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS .ISBUED.ILW WCWCEAB'INSLIRANCE CARRIER AND POLICY NUMBERARE CARRIER w "BECIGNM MDNOTBEOOLBIMMOFTHEPEY OFOROlEM,CFWDOUJIRBRIO%ORUM% 8 Z ICERTIFYTHAT LATHE PERFORMANCE OF THE VOW MAVM104THM PERMIT IS ISWED.J.. S2 SHALLNOT 9/PLOYAW PERSON IN ANY MANNER SO AS 70 BECOME SUBJECT TO THE cc WORKERS' COMPENSATION LAMB OFCALIFORSAANDAOREETIATi1&OUIDBECOME 5 SUBJECT TO THE RS'COWEiSA70N PROVISIONSOF SECTION Y!••OF THE LABOR COMPLY WITH,HOSE PROVISIONS. - DATE APRiGUi7` YJNVYHR F ENIORtE W COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SU191ECTAN, EMPLOYER TO CRIMINAL PENALTIES AO CIVIL FEES UP TO ONE HUNDRED THOUSAND DOLLARS(g ok000PLO),IN AD MOM TOTE COSTOF COMPENSATION. DAMAGFSASPRIOVDEDFORIN SECTION am OF THELABORR CODE. mwimi jAND ATTOFIEMS FEES. CC LU pi CONSTRUCTION LENDING AGENCY Q�C I HMAYAFFIRM UNDER PENALTY OF PEALIURY THATTHERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WowcNAICIT THISv rtB ISSUED (SE .7, CN.CI. LENDERS NAME STATE THAT THE ABOVE I/FOR ATION IS CORRECT. Q, I CERTIFY THAT I HAVE READ THIS APPLICATION AND IAOREE70 COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING Z CONSTRUCTION, AND HEREBYAURDN2E REPRESENTATNESOF THIS COUNTY TO ERER UPON THE ABGVE 6SOMED FOR INSPECTION PURPOSES. go a pEIIAIiTEE ro U V fA SIGNATURE OF PEAMrTTEE - _ _ _ - _ DATE LION FIRM APPLICATK)N Q g 10 NUMBPERMIT P/C DATE (j NUMBER ;gig 400 .. TYPE Qc0 DATE CONST. GROUP ZONING SETBACKS. - FRONT _.. RW ❑._-__r_ REAR ❑ SIDEGIDE STREET RW ❑ SIDE _ ❑ - CONSTRUCTION I LTV • c�J PLAN REVIEW ELECTRIC PAID PLUMBING MECHANICAL INSPECTION FEE ISSUANCE RAD -SNIP .. .crl'y tipB U AND ENERGY P!C - : oy�O .:.- . ENERGY PERMIT RETENTION FEE: PRE-ALT FEE TOTAL FEES COMMENTS ' RECPT. NO. PAID BY VALIDATION WHITE--DWwtmBM CGpy, YELLOW—Fk-- Copy. PINK --AB— Copy. 1 G. J1 I r _ i { I ¢� • i µ O�Q Q 1 %zjW _ � z¢ T • rmp- in�p� 00 mmZzm O Z za 13 0 Q T-W U �z ZQ mpp 0C3p �c7 2zt=O03 z QU. n~w _ W LLLL Up QQCO Z' QZ 2 U` 2 Ur JWz.WHZ`Y—O0. 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