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HomeMy WebLinkAbout15625 ��C���-� � CITY OF DIAMOND BAR , �---��� DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES l � 21660 E.Copley Drive 3uite 190 �(� ��( �( : (909)860-3195 Fax(909)861-311� � � PRESS � ��„��J� BUII.DING PERMI'T APPLICATION ( FIRMLY �:. o� JOBSITE i�d�� ,,,�J f;s.���� �� APPUCATION PERMIT �rp'�"-- P/C ADDRESS J � r�✓�� DATE � NUMBER [� # c� ISSUE /y TYPE OCC APN_ �OT TRACT DATE U' CpNST. GROUP p OWNER � �'` ADDRESS -37 °'� /Tl1S C � ZONING SETBACKS � CITY ��I'�td ZiP 0?�S-TEL. � ' -�. FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDElSI�E STREET RW ] CONTRACTOR '4 d�--. SIDE p ADDRESS s%' � CITY ef�<�(elJ2_ ZIP TEL. �+ � PROPOSED USE ��rL� � � o ARCH/ENG! � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFR/AD�/REM [] 1 HEREBV AFFlPM UNDER PENAL7Y OF PEHJURY THAT I AM EXEMPT FRORI THE CON7RACTORS LI- Gaf190/C3IpOR W CENSELAWFOR7HEFOLLOWINGREASON(SEC.7o37.6BUSINESSANDFROFESSiONSCOOE:ANYC�TVOR (n ZCOUNTYWHIq1REOUIRESAPERMRTOCDNSTRUCT,ALTER,IMPROVE,DEMOLISH,ORHEPNFiANYSTRUG (1,I p&ti0/DeCk W TUqE,PRqP TO RS 13SUANCE,AL50 REWIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNEO w .� STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE fANTRACTORS 41� � CENSE LAW�CHAPTER Y(COMMENCINO WITH SECTION 700oJ OF OIVISION 3 OF THE BUSMESS AN�PRO- LL' POOVSPB FESSIONSCOOE)ORh1ATHEOH5HEI5EXEMPTTMEREFqOMANDTHEBA315FOR7HEALLEOEDEXEMP• C7 TIOIV.ANVVbUTIONOFSECTION7031.66VANYAPPLICAYTFORAVERMITSUBJECTShIEAPPLICANT70 Z Re-Roof � AdVIL 7ENALiY OF NOT MORE THAN FNE HUNDRED DOLLARS(S5oo}.�: � DI,ASOWNEROFTHSPROPERTV,ORMVEMPLOYEESWITNWAGESASTHEIRSOLECOMPENSATION, � Commorcial -� yALi.DO THE WORK,AN�THE STRUCTURE IS NOT INTENDED OF OFFEREO FOR SALE(SEC.7a4I,BUSI- J NESS M10 PROFESSIONS CODE:THE CONTRACTDRS LICENSE UW�OES NOT APPLY TO AN OWNER OF � PpOPEHTYN710BUILASORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR = � THHOUGMHISORMEqOWNEMPLOYEES,PROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR m � OFFEREDWRSAIEIF,HOWEVER,7HEBUILOWGORIMPROVEMENTISSOLDWITHINONEYEAROFCAMvIE- Z TpN,THE OWNER-BUILDER 1MLL HAVE'�1E BUR�EN OF PHOVIN�h7AT HE OR StiE DIO NOT BUllp OR � IMPROVEFORTHEPURPOSEOFSAL�. �y,� OI,ASOWNEROFTHE�ROPERTY,AMEXCLUSNEIYCONTRACTINQWIiHLICENSmGONTMCTORS � TO CONSTflUCT THE PR41E(:T(SEC.7044,BUSWESS AND PROF'ESSIOMS COOE:THE CONTRACTORS L�- V81UdIi0l1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUIL�SORIMPROVESTFIEREON,AND � W/IOCOMRACTSFORSUCHPR0.1EC75WITHACONifiAC70R(S)LICENSEOPURSUANTT07HECONTRAG QUANTITY DESCRIPTION FEE � TOqS LICENSE UW J. Q �I AM EXEMPT UNDER SEC.! B.&P.C.FOF THIS REASON � 3 — a � DATE ONXJER a' Z W Q LICENSED GONTRACTORS DECLARATION J � w 1 HEREBV AFFIRM UNOER PENALT'�OF PER.IURY iMA77 AM LICENSED UNDER PROVISIONS OF CHAPTEq r ef/�r ry �-�.� � B(COMMENCINQ YATH SECTION 7000)OF DIVISION 3 OF THE BUSINES¢AND PROFESSIONS CODE,AND w X MY UCENSE IS AN FULL FOflGEAND£FFECT. �^" J LLI L� `� � LICENSE CUSS �� ��-I.IC.NO. �/�/���� �/ � V DATE� L'�- ".R�. CONTRAC70R d _ a �.: W � WORKERS'COMPENSATION DFCLAR ION C�q 1 -� � 1 ! `� � I HEREBV AFFIRM UNDER pENALTV OF PERJURV ONE OF THE FOLLO NG OFCUFATION. 7 � Q � ,IHAUEANDWILMAINTAIMACERTIFICATEOFCONSENTTO ELF-INSUREFORWOFKER5� �� _ COMP N.RSPROVIDEDBYSECT1CN370oOFTME ORGODE.FORTHEP Rf'bRMANGE W OF WOflK FOR WHICH THIS PERAd1T IS ISSUED. ,� W ,1 HAYE ANO WILL MAINTAIN WOAKERS'COMPENSATIOtd INSURANCE.A3 REQIIIRED BY SECTION 4 37o00FTHELA80 PE,FORTHEPERWRMANCEOFTHEWORKFORWHICHTNISPEqMIT15. � ISSl1EC�.MY E IXIMPENSATION7NSURANCECARRIER/APCT�O �Y�L1MBERARE: ONST UC E (.s(���"� � CAfiR1ER ��l c �(�1 V� z VOLICV Nt/MBFfi�� ? LI�4±__C_�--�.!►.�. .__ - L TRIC d Q (RU3SECTI�NNE�hlO'fBEIXkAR.LTFTiOFi}+EPEMfTISWP F0.1NCN7ED lS1oD� W I CEFiTIF'�THAT IN THE PERFORMANCE CF THE WORK FOF CH T R I !S ISSU ,I MECHAN L C7 SHALL NOT EMPLOV ANV PERSON IN ANV MAN O O UB C TO T � WORKEAS'COM7ENSATIONLAWSOFCALI NIA, ETMAT I5, UDB ME INSPECT NFEE SU&IECTTOTHEWONNERS'CAMPENSATI P O SE N37000 T 1A80R � GODE,I SH ,F�O/HT�HWITH COAIPLY WITN HO 5 . ISSl1ANCE -- p DATE:�'_.,�V4� APPLICnNT: SMIP ___ . W ENERGY P/C 'J WAflNING.FAILURE TO SECUFE WORKEPS'COMPENSA COV AGE IS WFL�' AND SHAIL BE ����--s�"�•� LL SU&IEC7ANEM�LOVERTOCRIMINALPENALTIESANDC'VI UPTDONEHUb6REDTHOUSAND ENERGYPERMIT DOLLARS(i100,000).IN ADDITION TO THE COST OF COMFENSATION,DAMAGES AS PROVID6D FOR IN J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTOPNENS FEES. RETENTION FEE: ' �' � CONSTFUCTION LENDING AGENCY PRE-ALT FEE: �f� �`'� � � '� +T� �y,ry�q � IHEREBYAFFIRMUNDERPENALTYOFP6RJURYTHATTHEREISACONSTRUCTIONLENOINGAGENCY �F�""67 irS.�.e +,n�iT P�J����I'�i�8'S,"1.iC �-' FOR THE PFRFOflMANGE OF THE WOFK FOF WHICH TMIS PERMIT IS ISSUE�(SEC.3087,CIV.C.). g'��� '�` ' �p,"�"yjg� ��,'`'(�'(p ' WL'�T�..�'.+✓—�fiT4�- .�' _.•—.—�.��°5w 9 4 , � IENDER'S NAME � LENDER5AODflESS � � ICERTIFYTHATIHAVEREADTHISAPPLICA710NANOSTATE NEABOVEMFORMA710NISCORFECT. TOTAL FEES W IAGREETOCAMP�VWITHAL.LCITYANDCOUNTYORDINA NDSTATEUWSRELATING70BUILDING � CONSTRUCTION.AND HEAEB�AUTHOR RESENT E OF THIS COUNTY TO ENTER UPON THE Z ABOVE-MENTIONEO 7flOPERTY F0 URP SE. COMMENTS o % -' /st _ ¢ PERMITTEE N (PRI - `/,�y �� UJ `� a- � SIGNATUflE OF PERMITT E DATE _ � RECPT.NO._____ PAI�BY IDATION ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Go GOLDENROQ-Fila Co GREEN— licant's Co P PY, PY. PY. 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