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HomeMy WebLinkAbout16285 ������� CITY OF DIAMOND BAR L� � ^aR --- --- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � f�p/� r 21660 E.Copley Drive Suite 190 � W (909)86(�3195 Fax(909)861-3117 ' PRESS \�.p�..... . . , . . ...�. . . - .: . . ... . . . BUILDING PE APPLICATIOI�T F�RM�. Q � � , ` �,.�,/+ . DATEICATION� Q� ..., ,., NUMBE .:: ,�.�. :,. �. ,:,,>, ,, � JOBSITE � R i �,� #� a ADDRESS +G OCC � APN L.OT TRA DA EE L -[ I� ONST. GROUP p OWNER p ADD ESS ZONING SETBACKS � CITY �` I TEL FRONT RW ❑ APPLI A �— TE REAR � zd SIDE/SIDE STREET Ryy p � CONTRACTO SIDE � ADDRESS . , Q CITY � Z�P TF�, PROPOSED USE S - , o ARCWENG/ S � z DESIGNER � � AODRESS NO.DWELw ` O. NO.-" � cn UNITS P STORIES �_gEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PEN/LLTV OF PERJUHY THAT 1 AM E%EMPT FROM THE CONTRACTORS ll- G8f9gB/Cflf()012 W CENSEUWFORTHEFOILOWINOREASON(SEC.7031,59USINESSANOPROFE9510NSCADE:ANVCINOR (n 4� COUNTYWFi01RE0UIFlESAFERMITTOCONSTRUCT,ALTER,IMPROVE,OEMOUSH,ORREPAIRANYSTPUC- LL� TUAE,PRIOR TO ITS ISSUANCE,ASO REQUIRES 7HE APPLICAN7 POR SUCH PEHMI7 TO FILE A 516NEp W PatiO/DeCk � STATEMENT 7HA7 HE OR SNE IS LICENSE�PUFi5UM1T TO THE PqOVI510NS OP THE CONTRACTORS L4 � CENSE LAW(CHqPTER G(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- PO01/Sp8 FESSpNSCODE�ORTHATHEORSHEISE7(EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� TION.ANYVIOUTIONOFSECTION7037.SBYANYAPPIICANTfORAPERMITSUBJECTS7HEAPPLIbAN7T0 Z Re-Raof � A CML FEMALTY OF NOT MOFE THAN FIVE Hl1NDRED DOLURS(SSCo).): � OI,ASOWNEROFTHEPHOPERN,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COf11fI10fC18I - VALL DO THE WORK,AND hIE STRUCTURE IS NOT IN7ENDED OF OFFEFiED FOR S�LE(SEC.7od�,BU54 ,J � NESS AND PFlOFESSIONS WDE:THE CONTRACTOPS LICENSE UW OOES NOT APPLY TO AN OWNER OF � PROPERTV WHO BUILDS OR IMGROVES THEflEON,AND YMO OOES SUCH WORK HIMSELF OP HERSE�F OP WTMRDUGNHISORHEROWNEMPLOYEES,PROVIDEDTFUTSUCHIMPROVEMENTSARENOTINTENOEDOR m Q ,OFFEREOFORSNEIF,HOWEYER7HE&11LDINaORIMPROVEMEN�I550LDWRHINONEYEAROFCOMPIE .Z TION,THE OWNER•BUILDER WILL HRVE THE BUPDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OH = IMPROVE FOHTHE PURPOSE OF SALE). W ❑I,ASOWNEROFTHE�R6PER'TV.A0.iE%CLUSIVELYCONTFtACTNOWRHLICENSE000N7PACioRS � TO CONSTRUCT THE PRQIECT(SEC.1au,BUSINESS AND PqOFESSIONs CODE:THE CONTqACTORS tl- ValUation ADJ.AREA W CENSELAWOOESNOTAPPLVTOANOWNEROFAPROPERT'WHOBUILDSOHIMPROVESTHEREON,NA � WHOCONTRAC7SFORSUCHOROlECTSWITHAC6NTRACiOR(S)LICENSEDPURSUANTIOTHECONTMG qUANTITY DESCRIPTION FEE � TORS LICENS'e UW.�. � — ❑IAM EXEMPT UNDEH SEC._ B,8 P.C.FOfl TMIS flEASON Q 3 � LL OATE OWNER � Z _ U � LICENSED CONTRACTORS DECLARATION W 0�'C 1 HEREBV AFFIRM UNDER PENALTV OF PEtUURY TNAT I AM LICENSED UNOFR PROVISIONS OF CHAPTER � a, 9(COMMENCiN(aWITHSECTION7o00)OFDIVISION30FTHEBUSMESSANDPqOF[SSIONSCODE,AND Z }C MV LICENSE�S IN iULI.FORCE AND EFFECT. � L� LIGENSE CUSS � . �r Lf0.NO. r ��L.� � V DATE G CONTRACTO d W ✓ � WORKERS'COMPENSATION OECLARATION Q � 1 HEREBV AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOL:.OWING DECIAflATIONS: � � _IHAVEANDWILLMAINTAINACERTIPICATEOFCANSEN7TOSELFINSUREFORWORKERS' 2 CAMP£NSATION,AS PROVIDE�BY SECTION 3�0o OF THE UBOR CODE,FOR THE PERFORMANCE �U � UF THE WORK FOR WHICH THIS PERMIT IS ISFUED. � �RAv�ANOWILLMAINTAINWORK 5'COMPENSATIONINSURqNCE,AS E IFED6YSECT!ON � 37oaOFTHELA80RCODE,FORTEPEHFORM CEOFhiEWORKF HICH7HISPERMITIS �n�' �� � ISSUE�.MY WORKERS'COMPEI ATION INII M16EEAR LICV NUMBEF . CONSTRUCTION �J �'V � cnaaiea_ - PLAN REVIEW z voucvNu�eER__ _ �' � _� — ELECTRIC 4 0 (iHISSECil01JN�NOTBEClJNPt..EfEDOFTHEPEPoAi45FOqIXJEHUNUFiE�D0UAR5�ElaD)ORL65�. PLUMBING Z ICERTIFYiHATINTHEpERFORIAANCEOFiNEM/ORKFORWHICH7HI5PERMI7ISISSL/ED,I MECHANICAL Ci ^uHALL NO7 EAIPLOY ANY PERSON IN ANV MANNER SOAS TO BECOIdE Sl1BJFCTTO THE � W�RKERS'COMPENSATION LAWS OF CAUfORNIA,AND AGREE THAT IG I SHOULD BECOME INSPECTION FEE = SUBJECTT07NEWORKERS'COI.IPfNSATONPROVISIONSOFSECTION37ooOFTHELABOR COOE,I SHN1 FORTHWI7N COMPLY WITH THOSE PROVISIONS. ISSUANCE O p DATE:_ APPLIGANT. SMIP � / J WAqN�NG:FAILURE TO SECURE WOflNERS'COMPENSATION COVEPAGE 15 UNLAWFUL,AND SHALL BE ENERGY P/C � SU&IECTANEMPIOVERTOCRIMiNALPENALTIESANOCIVILFINESUPTOONEHUNDPEDTHOUSAND ENEAGYPERMIT DOL.LARS(i�W,000�.IN ADDITION TO THE COST OF COMPENSATIIXJ,DAMAGES AS PROVIOED FOR IN � SECTION97000FTHELABORCODE,INTEREST,ANDpTTORNEVSFEES. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-AlT FEE: � I HEREBV AFFIRM UNbER VENALTV OF PERJURV THATTHERE IS ACONSTRUCTION LENDWG AGENCY - . FOR THE PERFORMAhCE OF hIE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.30B1,CIV.CJ. . Z W � LENDER'S NAME � , F— LENDER'S A�DRE55 � TOTALFEES �� � I CEHTIFY THAT I HAVE PEAD THIS APPLICATION AND STATE THATTHEABOVE MFORMATION IS CApRECT, W I AGREE TO COMOLY WITH ALLCRY AND COUNTV OROINANCES AND STATE LAWS RELATING TO BUILDING d � CONSTRUCTION,AND NEREBY A TNORRE REPRESENTATIVES OFTNIS COUNTY TO ENTER UPON THE � � Z. ABOVE-MENTIONED PROPERTV OR INSPECTION PURPOSES. COMMENTS 0 _ 'f.+�-_�'� m PERMI EE NAM RIN ' Q .,� - C/J � SIGNAT OF E = RECPL NO. PAID BV . 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