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HomeMy WebLinkAbout16734 � _�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � ,� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '��^^� BUII.DING PERMIT APPLICATION FIRMLY '� DDR SS .'�� lfLllC.+�-. 1�.T p . t, , . T l„ � PPUCATION ' "1"�L�. PERMIT � ..� /C a (� ATE ( --� NUMBER # r� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER � � ADD ESS ZONWG SETBACKS w CITY ZIP y TEL.J��'I�"'eII REO�NT RW o � APPLICANT ,_ TEL. SIDE/SIDE STREET RW ❑ � C�NTRACTOR` SIDE ❑ � ApDR SS � CITY ZIP TEL. - PROPOSED USE w ARCH/ENG/ Z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFWADD/REM p I HEHEBY AFFIRM UNDER PENALTY OF PEPJURY 7HAT I NA E%EM7T FROM TiE CANTqACTORS LI- � Gflfage/CefpOrt W CENSEUWFORTHEFOLLOWINOREASON(SEC.7031.SBUSMESSANOPROFESSIONSCQDE:ANYCITVOR C� COUNTVWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTFlUC- W patiol�eCk W iURE,PRIOR 70 ITS ISSUANCE,AL50 RE�UIFES THE APPUCANT FOR SUCH PERMI7 TO fILE A SIGNED .� STATEMENT TrUT HE OR SHE IS LICENSEU WRSUANT TO THE PROVISIONS OF THE CON7NACTOR$LI� � CENSE LAW�CHAPTER 9�COMMENCINO WITN SECTION)OOa)OF DIVISION 3 OF THE BUSINE55 AND PRO� �'�' PDOUS{18 FE6SIONSOODE�ORTMATHEORSNEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP• (� U TION.ANYYKKATIONOFSECTION7031.50YANYAPPUCAfJTFORAPERMIT3UBJECTSTHEAPPUCANTTO Z Re-Roof � ACIVI4 PENALTV OF NOT IAORE THAN FIVE HUN�REO�OLUNS(fsao).)� � qI.A50WNEROFTHEPROPERTY,OPMYEMPtAYEE9WITHWA6ESA5THEIRSOLECOMPENSATION, Q COmI710fClfll - N7LL DO THE WORK,AND THE S7RUCTURE IS NO7 INTENDm OR OFFEREO FOR SALE(SEQ 7044.BUSb J � NE55 AND PROFESSION9 CODE TME CONTRAC70RS UCENSE UW�OES NOTAPPIV TO AN OWNEP OF ? PROPERTV Nh10 BUIL.�S OR IMPROVES iHEREON.ANO WHO DOES SUCH WORIC HIMSELP OR MERSELF OR � THROU(3HHISORHEflOWNEMP40VEES,PROVIDEDTHATS�CHIMPPOVEMENTSARENOTINTENDE00R m QOFFEREDWRSN.EIF,HOWEVER,TiEBUILUINGORIMPROVEMENTI550LDW17MINONEYEAROFCOMPIE- z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PPOVINCi TNqT HE OR SHE DIO NOT BUILD OR = IMPF�VE FOR TME PURPOSE OF ShLE). w pI,A50WNEHOFTHEPROPER7Y,AMEXCLl151VELYCONTRACTINGW1T11LICENSE000N7RAC70RS � TO CONSTRUCT THE PROJECT�3EC.�WR,BUSINESS AND PRDFESSIONS CODE:THE CONTflACTORS U- VOIUdIIOfI ADJ.AREA CENSE UW OOES NOT MVIY TO�N OWNER OF A PROPERTY WHO BUILDS Ofl IMPROVES THEflEOIV.ANI] � W}1DCONTMCTSFORSUCHPFlOJECTSWITHACONTRACTOR�S�I�CENSEDPURSUANT70THECONTqAC- (aUANT�TY �ESCRIPTION FEE � TORS LICENSE UW.}. - J Q ❑IAM E%EMPT UNDER SEC. B.&P.C.FOR THIS REASON � �! a LL �ATE OWNER U � � � LICENSED CONTRACTORS DECLARATION W � �HEREBYAFFIRM UNDER PENALTV OF PERIURY TFlAT IAM UCENSE�UNOER PROVISIONS OF CHAPTER � s 9(COMMENCIN(4 WITM SECTION 7000)OF DIVISION 3 0F THE�151NESS ANO PROFESSIONS COD'c,AND � X MV LICENSE IS IN NLL FORCE AND EFFECT. m `0 LICENSE C 55��/�L� L.-_ LIC.NO.___(__�'� � � DATE � �� SL� CONTflACT�OR�,. 3� _ n- W j�(1 , � WORKERS'COMPENSATION D CLA ATIO�� �"'� a N IHEREBYAFFIRMUNDERPEN/1LTYOFPERJUFYONEOFTHEFOLLOWINGDECIAFATIONS: � � � Z 6 � _.IHAYEAND'N�LLMAINTMNACERTIFICATEOFCONSENTTOSELFdNSUREFORWORKERS' x -- COMPENSATIqN.AS PROVIDED 0Y SECTION 370o OF THE LABOR COUE,FOR TNE PERFORMANCE `U aF TME WORK FOR WHICh17MIS PERMIT IS ISSUEO. � 0 __ W _I HAVE AND W!LL MAIMAIN WORKERS'GOMPENSATION IRSUHANGE,AS REQUiREO BY SECTKIN 4 a7ooOF7HE 1.A80R CAOE,FOR THE GERFOFMANCE OF iHE WOflK FOH WHIr.H iH15 PERMI7 i5 0 ISSUED.MY WORKEPS'COMPENSATION INSLIRANCE CAP.RIERANO POL�CY NUMBERARE: CONSTRUCTION � CARRIFRS �_��� � PLAN REVIEW � POLICYNUMBEP ����''� -7--1.� ELECTRIC �[ p Rt+c;SECTqNNE�NOTBENMPLEfEDOFiHEPERlxftSFORONEHUI�DNEDDOtLARS(S1oo10RLESs1. PLUMBING W Z I CERTIFYTHAT IN THE PERfORMAVCE OF iHE WORK FOR WNICH THIS PEPMIT IS ISSUEO,I MECHANICAL a1S. � (,'3 SHMINOTEMPIOYANVPEFiSONINANVMANMER5�A5TOBECOMcSU&IECTTOTHE (p WOflNERS'COMPcNSATION IAWS Of GALIFORNIA,AN0 AGREE THAT IF I SHOl1LO BECOME INSPECTION FEE SU&IECTTO THE WORKERS'COMPENSATION VR041510NS OF SECTION 3700 OF THE LABOR ���/^\ � CIX7E,I SMALL FCR(HW17H COMPLY WI7H TMOSE PROVISIONS. ISSUANCE �/��/ � SMIP p �ATE: _._ APPLICANT: _ J ENERGY P/C WAftNIHG�FAILI1FiE TO SECURE WORKERS'COMPENSAiION��ERAGE I5 VNLAWFUL,ANp SHALLBE LL SU&IECTANEMPLO�ERTOCRIMINALPENALTIESAN�CIVILFINESIJPTOONEHt1NDREp1HOUSAND ENERGYPERMIT DOLLNNS IS700.000),IN ADDITiON TO THE COST OF COMPENSATION,DAMAGES AS PRW�DEO FOR IN � SECTON 37oe OF TiE LABOR CODE,WTERES7,AND AT70RNEY'S FEES. flETENTION FEE: � CONSTRUCTION LENDING AGENCY PREALT FEE: � I NEREBY AFFlPM UNOER PENALTY OF PERJUflV THAT THERE IS ACONS7RUCTION LENDING AGENCY FOR THE PERFOflMANCE OF THE'�✓�AK FOR WHIGH THIS PERMIT IS ISS�ED(SEC.30B],CIV.C.), Z W � LENOER5 NAME !_ LENOEFISA�DRESS {`.�� W ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHA7THEABO�EINFOFMATIDNISCARRECT. TOTAL FEES ��Y� �,/ d IAGREETOCOMPLYWITHALIC�'�1'ANDWUN�'OfiDINNJCESANDSTATEL4WSRELATINGTOBUIL0ING V� CONSTRLICTION,AMD HEREBY AUiHORRE REPRESENTATIYES OF THIS COUNTY TO ENTEN UPON THE ZABOYE-MENT70NE�PROPEFTYKORINSPECTIONPURPOSES. 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