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HomeMy WebLinkAbout17176 CITY OF DIAMOND BAR --- �'�`� -- DEP/4RTMENT OF COMMUNITY&DEVEIAPIvIENT SERVICES I 21825 E.Copley Drive (909)860-3145 Fax(909)861-3117 PRESS %y��` BL�ILDING PERMIT APPLICATION FI LY o ADDRESS�S(S � ��u. ry�y APPLICATION '� � � NUMBER�j��1� #/C � �J� y�F� DATE � ISSUE • �' TYPE OCC APN LOT TRACT_��� DATE CONST. GROUP p OWNER �� . _ o ADDRF�S�S�,�/ �� L1M� ZONING SETBACKS OCITY�D�7 P�f� ZI TEL. _ " I�1 FRONT RW ❑ APPLICANT TEL REAR ❑ � SIDE/SIDE STREET RW ❑ ¢ CDNTRACT � SIDE ❑ Q ADD SS ,,,,,, ,,,,E o CI ZIP TEL. �Y �� w ARCH/ENG/ �! z DESiGNER N .OWEL. NO. N . � A�DRESS UNITS STORIES BEDROOMS�` � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFR/ADD/REM p I HEftE6V AFFIRM UNDER PENAL71'OF PEiiJURY THAT I AM EXEMM FROM iHE CONTRACTORS LI� G8f8JB/C3fP011 W CENSELAWFORTNEFOLLOWMGREASON(SEC.7031.SBUSINESSANDPFOFESSIONSCODE:ANVCIT�'OR (n U COUNTYNhIICHHE�UIRESAPERMITTOCONSTRUCT.ALTER.IMPROVE,DEMOLISH,ORREPAIRANYSTRUC� W PatiolDeck w 7URE,PFIOR TO ITS ISSUANCE,ALSO REOUIRE3 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W .� STATEMENT THAT HE OR SHE IS LICENSEO PURSl1ANT TO THE PROVISIONS OF TME CONTRACTORS LI� .� CENSE LAW�CHACIER e(COMMENCMG WIiH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PRO� LL' PooUSpa FESSIONSW�E�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISfORTHEALLEGEDE%EMP� (� 0 TION.ANVVIOUTIONOFSECTION7031.58VANYAPPUCANTFORAPERMITSUBJECTSTFIEAPPUGANT'O Z Re-Root � A CIVII PENAL7V OF NOT MORE THAN FIVE HUNORED DOLUIRS(E500�.)� � ❑I,ASOWNEROFTHEPROPERTV,ORMVEMP�OYEESWITHWAGESASTHEIRSOLECOMPENSATION, O COfi1rt18fCi8I Z WILL DO 7HE WORH.AND THE STRUC7URE IS NOT IN7ENpED Oii OFFERED FpR SALE(SEC.7a44,BU51- J NESS ANO PflOFC-SSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPIY TO AN OWNER OF � PROPERTYNMOBUIlO50RIMPROVESTHEREON.ANONMODOE55UCHWOflKMIMSELFORHERSELFOR � � THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDE�OR m W OFFEREDFORSAIE.IF,HOWEVER,hIEBl11LDMGORIMPROVEMENT6S�LDWITHINONEYEAROFCOMPLE- 0 TION,TME OWNER-BUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OF SHE DID NOT BUILD OR Z IMPROVE FORTHE PURPOSE OF SALE�. = f11,A50WNEROFiHEPROPERTY.AME%CLUSIVELYCONTRACTING`MTHLICENSEDCONTRAGTORS W � TO CONSTFlUCT THE PR0.IECT(SEC.7044,Bl15WE5S AND PROFESSIONS CODE:THE CONTRACT09S LI- VdIl12fI0f1 ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNE90FAPROPERTYWH08UILDS�RIMPROVESTHEREON.AN� � WHOCOMRACTSFORSUCHPq�JEGTSWITHACONTRACTOR(S)LICENSEDPUPSUANTTOTHECD�TRAC- �UANTITY DESCRIPTION FEE Y 70RS LICENSE LAW.). � � J I � ❑IAM EXEMPTUNDER SEC. B.8 P.C.F09THIS REASON Q� � U ¢ LL' DATE�___ OWNER � Z w � LICENSED CONTRACTORS DECLARATION W � IHEREBVAFFIRMUNDERPENALTYOFPERJURYTHATIAMLICENSF.IiUN�ERPFOVISIONSOFCHAPTER � d 9(COMMENCINGWITHSECTION)0oo)OFDIVISION30FTHEBUSINESSANOPROF[SSIONSCOD[,AN� z `X MV UCENSE IS IN FULI FORCE AND EFFECT. m � LICENSE C SS �IC.NQ � � U OA7E �' � CONTRAC70R W � WORKERS'COMPENSATION DECLARATION a = U � IHEREBVAFFIRMUNDERPENALTVOGPERJURYONEOFTHEFOLLOWINGDECLARA710N5: � Z Q � _IHAVEANDWILLMAWTAINACERTIFICATEDFCONSENTTOSELF-INSUPEFORWORKERS' _ CAMPENSATION,ASPROVI�EDBYSECTIDN3�oDOFTHELABORCODE,FORTHEPERFORMANCE U a OFTHEWORKFOPWHICHTHISPERMITISISSUED. � � w _t NAVE ANO WILL MA�NTAIN WORK[RS'COMPENSATION INSURANCE,AS RE�UIREp BY SECTION �.r O 370a OF THE LABOR DE,FOfl TF+E PERFOR6IANCE OF THE WORK FOR WHICHTHIS PERMIT IS e ISSUE�.MV WOR pENSATION MSUqO CARRIER AND POLICY NUMBERAR�: CONSTRUCTION � � � J T j cqqq,ER� __ P�AN REVIEW Z POLICY NUMBER '� ELECTRIC a (�I-I�SSECTIONNEmNOTgEWMPIEfEDOFiuEPERM1YTISFORONEHUNDRED00LLfdiS!SIOOJORLESS). PLUMBING � w MECHANICAL Z ICERTIFYTHATINTHEPERFORNANCEOFTHEWOPKFORWHICHTHISPERMRISISSUE�,I (�$ SNAIL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO 9ECCME SUBJECTTO THE � WORKERS'COM7ENSATION LAWS OF CALIFORNIA,ANOAGREETHAT IF I SHOULD BECO!.1E �NSPECTION FEE �y F; SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIOM1SOFSECTION37000fTHElP.BOR y� � CODE.I SHALL�ORTHWITH COMPLV WITH THOSE VROVISIONS. (SSUANCE � SMIP �[� p DATE:_.__.. __ APPLIGANT: — — w ENERGY PIC J WARNWG FAILURE TO SECURE WORKEflS'COMPENSATION CCVERAGE IS UNL4WFUL.AN�SHALLBE �y SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS(5100,Wo),IN AD�1TION TO THE COST OF COMPENSATION,�AMAGES AS PROVIDECf FOR IN � SECTION3]�JBOFTHELAHORCODE,INTEFEST,AN�ATTORNEV'SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFlRM UNOER PENALTY OF PEPJUPY THAT THEflE IS A CONSTRUCTION LENOMG AGENCY 0- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.309�,CIV.C.). '-��--- Z W - S LENDER'S NAME � F_ LENDER'SAD7RES5 -_____ �J i � IGERTIFVTHA7IHAVEREADTHISAPPLICATIONANDSTATETHATTHEN30VEWfORMATION15CORRECT. TOTALFEES � ,/� � IAGREETOCOMPLVWITHALLC'TVANDCOUNTVORDIN0.NCESANOSTATELAWSRFLATINGT08UILDING � CONS7RUGTION,AND HEREB�AUTHORIZE REPRESENTATIVES OFTHIS COUMV T4 EYTEfl UPON THE ZABOVE-MENTIONED P OP TV FOR INSPEC710N PURPOSES. COMMENTS � J � m PEflMiTTEE NA (?FMT� ¢ �I l �, - _ _ . � SIGNATUREOFPE ��DATE ' " = REGPT.NO. _ PAID BY __ VALIDATION ~ WHITE—�epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOL�ENROD—File Copy,GfiEEN—ApplicanPs Copy � . , . . ,_, .., .. . . µ . . . ,.,... .. TY . .x,�7; �aPy� �4..vai.•5d.h;u�e7,,y5�'t+'dp.....s�.;.�r.... .,.. . . ,.� „ r . . .. .., m, u,� .... , ,elld. .,��.... .. ....,...., .�.,,....,,,.,�.. .. .. ...,. .... .,. . �.r.p;�r.�...,. � r'f�� � z.A �, ��a �x . 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