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HomeMy WebLinkAbout17427 CITY OF DIAMOND BAR � 3 —�'�``--- DEPARTMENT OF COh�v1UNITY&DEVELOPMENT SERVICES I I i 21825 E.Copley Drive �� ' '''"' (9Q9)860-3195 Fax(909)861-3117 PRESS `"-yr��� BUILDING PERNllT APPLICATION FIRMLY � JOBSITE �*'' S APPLICATIO�N,� ,,, PERMIT P/C ' o ADDRESS_ J ����' DATE �//. � NUMBER �� # oro ISSUE `� TYPE OCC APN OT TRACT DATE CONST. GROUP � OWNER O p ADDR S `C��P ZONING SETBACKS z GITY IP .�TEL. FRONT ftW Q APPLfCANT TEL. REAR � o SID�F✓SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRE PROPOSED USE `� � � CITY �� Z1P��;�T . I w ARCH/ENG/ z DESIGNER NO.DWEL N�. NO. a ADDRESS - UNITS STORIES 6EDROOMS � CITY ZIP TEL. ' � DESCRIPTION SQ.FT. FACTOR PSF ADJ,AREANALUATION � ''�. � OWNER-BUILOER DECLARATION SFRIADD/REM O �, p I HEREBV AFFIRM 11N�ER PENALTY OF PERJUflY THAT I AM E%EMPT FROM THE CONTRACTORS LI- � GaragelCarport '� W. CENSEUIWFORTHEFOLLOWMGREASON(SEC.7D31.SBUSINESSANDPROFESSIONSCOOE:ANVCITYOR . . '' U COUNTYWHICHREOUIRESAPER ITTOCONSTRUCT,ALTEA,IMPROVE,�EMIOLISH,ORREPAIRANYSTRl1C- M � Patio/Deck ', � W TURE,PRIOR TO ITS ISSl1ANCE,pLSO RE�UIRES THE APPLICANT FOR SUCH PERMIT i0 FILE A SIGNE� � 57ATEMENT THAT HE OR SHE IS 410ENSED PURSUANi TO iHE PROVISIONS OF THE CONTRACTORS ll- � ' CENSELAW(CHAPTER9(COlAAAENqNGWIiHSECTION7�Jo0)OFDIVISION3DFTHEBUSWESSANO?RO� � POOVSPe O FESSIONSCO�E)ORTHATHEORSHEIS�EXEMPTTHEFIEFFOMAN�THEBASISFORTHEALLEGEOEXEMP� '� 'TION.ANYVIOLATIONOFSECTION'7o31.58VANVAPPLICPtdTFORAPERMITSUBJECTSTHEAPPLICANTTO Z RB-ROOf � 'ApVILPENALTVOFNOTMORETF{ANFIVEHLIN�RE��OLLARS(55ao)J: � ❑I,ASOWNEROFTHEPROPEflTY,OPMY�MPLOYEESWITH-WAGESASTHEIflSOLECOMPENSA710N, ❑ CORIR7EfCIHI Z WILL UO TH£WOAK,AND iHE SiAUCTURE IS NOT INTENDE�OR OFFERED fOR SALE(SEC.704a,eU56 J �NE55 AN�PROFESSIONS COOE:THE CON7RAGiORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF �' ��.PFOPERTYWHOBUILDSORIMPROVESTHEREON,ANOWHO�OESSUCHWOFKHIMSEIFORHERSELFOR m I �' THROUGHHISOPHEROWNEMPLOVEES,PROVmEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR � WQ. OFFEREDFORSALE.IFHOWEVE3,RFiEBUILDINGORIMPROVEMENTISSOLDWITHI�ONEYEAROFCOMPLE �, TION,THE OWNER-BUILDER WILL���AVE THE Bt1RDEN OF PROVMG THAT HE OFi SHE DID NOT BUIL�OR . �, ,IMPROVEFORTHEPIJRPOSEOF�LE).� OI.ASOWNEROFTHEPROP RTY,APAEXCLUSNELYCONTRAC7INGWITHLICENSEDCONTRACiORS '�. �'', ' TO CANSTRUCT 7HE PROJECT(S,C.]044.BU51NES5 AND PROFESSIONS CO�E'.THE CONiflACTORS LI- VHIU8Ci011 ADJ.AREA_. ' W� 'CENSEIAWDOESNOTAPPLYTOANOVJIJEROFAPROPEPiYWHOBUILD50RIMPPOVESTHEflEDN,AND � ��. WFIOCONTRACTSFORSUCHPqOJECTSWITHACONTflACTOR(SJLICENSE6PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE i TOflS LICENS�LAW.). � ' OY � � ' AM EXEMPT UNDER SEC, B.&P.C.FOR THIS REASO U � � � ��,� LL DATE OWNER V Z �. '� LICENSED CONTRAC70RS DECLARATION � '� � INEREBYAFFIFMUN�ERPENALTYOFP�RJURVTHATIAMLICENSEDUNDERPROVISIONSOFCHAPiER � d ,9(COMMENCING WITH SECTIaN 7a0o)OF DNISION 30F THE BUSINE55 AND PRtlFESo'IONS CODE,AND Z �X MY LICENSE IS IN FULL fORGEAN�EFFECL m � UGENSE CLASS �'II�'" ��— ^]/re.IC.NO. // �✓d� � � . , W pp7E CONTRACTOR �- �� WORKERS'COMPENSATION DECLARATION � � U � IHEREBYAFFlRMUNDERPENALNOFPERJUflVONEOFTHEFOLI�WMG�ECLARATIONS: z Q � O _I HAJE ANO WILL MAINTpIN A CERTIFCATE OF CONSENT TO SELF-INSURE FOP WORKERS' 2 ¢ CAMPENSAiION,AS PROVIDED BY SECTION 3�0o OF THE LABDR CODE,FOR THE PERFORMANCE W � OF THE WORK FOR WHICH�THIS PERM1715155UE0. � � W _IHAVEANDWILLMAINTAINWORKERS'COlAPENSATIONINSURANGE,ASflE�UIRED6Y5ECTION ''� Q 37Du OF THE LABOR CODE;FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PFAMIT IS — ' ISSUE�.MY WORKERS'COMPENSATION INSUPANCE CARRIER AN�POIICV NUMBER ARE: CONSTRUCTION , j CARRIER. PLAN REVIEW �,.� � POIICY NUM6ER ELECTRIC ;'�-� �' �� Q ��� 0 (f}iI55EC110NNEmNOTBECCMPLETEDOFiHEPEPMITISWRONEHl1NDRE0�01J_ARS(51LU)ORLESS). PLUMBING W ICERTIFYTHATMTHEPEAFOPMANCEOF?HEWORKFORWHICHTHISPERMITISISSUED,1 MECHANICAL . Z � ERSON IN ANV MANNE3 SO AS TO BECOME SL'B15CTTOTHE ('3 SHALLNOTEMPLOYANYNLAWSOFCALIFORNIA.ANOAGREETNATIFISHOULDBEGOME INSPECTIONFEE '-- ^t WORKERS'COMPENSATIO , � SUBJECTTOTHEWORKERS'COMPENSA710NPAOVISIONSOFSECTION37ooOFTHELABDR �� - ��� � CODE,ISHN.LFOR7HWITHCOlAPLVWITHTHOSEPROVISIO�S. ISSUANCE , � SMIP p OATE: APPLICANT. _ � � 7��(�� W ENERGY P!C � �� , ��. !;4;!j J WAFiNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEAAGE IS UNLAWFUL,AN�SHALL BE �y SUBJECTANEMPLOYERTOCftIMINALPENALTIESANOCIVILFINESUPTOONEHUNDftEDTHOUSAN� ENERGYPERMIT DOLLARS(5100,000),14 ADOITION TO THE.COST OI'COMPENSATION,DAMAGES AS PFiOVIDEO FOR IN �0 — � 5[CTION37GeOFTHELA80RCODE,INTEREST,ANDATTOflNEY'SFEES. RETENTIONFEE: � °'" W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �� - �� � � 1 HEREBVAFFIPM UNDER PENALTV OF P6RJUflV THAT THERE IS AGONSTAl1CTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR VJHICH THIS PERMIT IS ISSUED(SEG.309],CIV.C.). Z -- W S LENOER'S NAME _ —_. � F= LEN�ER'3ADDRESS /� C /e ¢ ICEflTIFYTHATIHAVEREADTHiSAPPLICATIONAN�STATETHATTHEA80VEINFORMATIONISCOFRECT. TOT/'1L FCES � � IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANOSTATELAWSRELATINOiOBUILpING � GONSTRUCTION,ANDHERE9YAUTHORREREPRESENTATIVESOFTHISCOVNTYTOENTERUPONTHE zA80VE-MENiIONED PROPERTV FOR INSPECTION PUFPOSES. 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