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HomeMy WebLinkAbout10004 � � � Fx - CITY OF DIAMQND BAR � I� Pf COMMUNTI'Y DEVELOPMENT DEPARTMENT� ��Q � .,. 21660 E.Copley Drive Suito 190 /�r (909)860-3195 Fax(909)861-3117 `/ O� , PRESS ��"'4 BiJILDING PERMIT APPLICATION �QO� FIRMLY � �'SS / - �O ��-'"�� �`*" /�.� �PPLICATION PERMIT � P/C ; DATE NUMBER p�� M $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GRQUP p OWNER �U�� "' ADOFESS 5��7 ZONING SETBACKS g APPIJCANT �P /S,r TEL, R�ORT RW �❑ � SIDE/SI�E STREEf RW ❑ CONTRACTOR L✓�L � U!� r . SIDE ❑ ADDFlE�uS � PROPOSED USE o CITY �IJR�+1 r%T ZIP�7� TEL. � w ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES �BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AAEANALUATION � � OWNER-B�ILDER DECLAAATIQN SFR/AD0lREM O p I HEREBY AFflRM UNDER PENALTY OF PERJUNY TNA7 1 AM EXENPT FROM THE CONTiUCTOqS LI• G3f8QB/Ca1p011 W CENSEUWFORiNEFOLLOWINGHEASON(SEC.7037.5BUSMESSANDVPOFESSIONSCODE:ANVCITVOH (f� C.) COUryTyWHlp{REW�RESAVERMITTOCONSTRl/CT,ALTEH,IMPROVE,DE40LI5H2ORREPAIRANYSTRUG W PeIiDlObtk wTUAE,P6WP TO ITS ISBUANCE,ALSO PEIX/IqES THE APPLICANT FOR SUCH PERAl1T TO FlLE�SIGNED W � STATFAIENT THAT HE OR SME IS LIGENSEO PURSUANT TO 7HE PflOVIS�NS OP THE CONTMCTORS LI� CENSE WN(GUPT6R e(COM4ENCINO WITH SECTION 7aoo)OF DIVISION 30F THE 8U61NESS M1D PP6 � P��� � FESSqNSCODE)ORTHATHEORSHEISEXENPTTHEREFHOMANDTHEBASISiOflTHEALLEGEDEXEMP• (� TqN.ANVVpLATIONOF5ECT10N7091.68VANVMPIICANTFORAPERMIT5U61ECT5TiEAPPLICAMTO qe_p�� `Q�j' � �p � A CM�VENALTV OF NOT HORE THIN FIVE NUN�PED OOLLARS(t5a0).): _ � ❑I,ASOWNEflOFTMEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIqSOIECQMPEN5r1TqN, d pmmercial Z M9LL DD THE WORK,AND THE STRUCTUPE IS NOT IMEAroED OR OGFERED FOR SALE(SEC.7ou,BUSI- J NE55 AND PROFESSIONS WOE:THE CONTRACTORS IICENSE UW DOES NOTAPPLY TO AN OWNER OF � PFqPERTYtNiOBUILDSORINPROVE5TLIEAEON.AN�W}IOOOESSII(%1WORKHIMSEIFORNERSEIFOR � � THHOU6NHi50NHEROVMEMPLOVEFS,PROVIDEDTHATSUCHIYPROVEYENTSARENOTIMENOE�OH m W OFFEREDFOHSALEIf,FIOWEVERTMEBU1l��NGOFIMPFiOVEMEMISSOIDWITHINONEVEAROFCOMRE � TION,THE ONMEREUILDEN W�LL HAVE iHE BUHDEN Oi PROVIN6 TNAT HE OR SHE 010 NOT PUILD OP � � 1Y➢ROVE FOH 7HE PURPOSE OF SALE�. w �t,ASOWNEROF�II£PPOPSRTY,NAE%ClUS1YElYCONTRRCTINGW4TNLICENS£OCONTRAC�ORS � � iD CONSTflUC7 iME PRO,IEG7(SEC.7oa{,PUSINESS AND PROFESSIONS�DE:THE CONTR4CTORS U• V21U8t1017 AQ1.ApEA W CENSELAWDOESNOTAPPLYTOANOWNEflOfAPROPFRTYWHOBVIlD50HIMPROVES'fHEREON,ANp � � N0.1000NTRACTSGORSUCt/PROJECT5Wi7H�CONTMCTOR(5)LICENSEDPVRSUMfTNTHECONTFUG QUANTITY DES RIPTIDN FEE � TORS UCENSE lAW), � O I AM EXEMGT Ut�IDER SEC. 8.8 P.C.FOFi THIS REASON � � � � ��'� LL DAiE OwNEH V � LICENSED CONTRACTORS DECLARATION W 2 Cy �� � 1 HEREOVAFFIRN UNDER PENALTY OF VERJURV TNAT IAM LiCENSED UNDEH PRONSIONS OF CHAVTEq .� � Y(CO4YENC1N0 WITH SECTION 7000)OF DIYISION 3 OF TME BUSINESSAND PROFESSION3 CODE,AN� z X MV LICENSE IS IN NLL FORCE�ND EFFECT .r� `)'` � � �� � IICENSECLASS � LIC.NO.��/•�/ / �` � j "r^^ U pq7E "Z � CONTMCTQfi �✓�•r� d � W � WORKERS'COMPENSATIONDECLAAATION O -� � IHEREBYAFfIRMUNDERPENALTYDFPERNHYONEOFi1�7EWLLOWINGDECIAfUT1045: �/ � C � /� �1 HAVE AND VnLL MAIN7A�N A CER71FlCA7E OF CONSENTTO SEIF-INSURE FOR WbF ERS' COMPENSQIQN,ASPftOVIDEDBYSECTION37000FTHELA8Q0.CQQEWRIHEPERfOFM W OF THE YYOPK FOR VMtIN]i 7HI5 PEflMiT I5 ISSUED. � � W _I HAVE AND WILL MAINTAIN WORKERS'COIAPENSATION INSURANCE,AS(iEIX1IRE�BY SECTIOH �J � 37ooOFTHE LAROR CODE,FOH THE PERFORMANCE OF THE WORK FOH WMIp17HI5 PEiM/1T iS _/ ISSUED.MY WORKER'?WMPFNSAT IN9UMNCE CARPoER ANO POLICY NVM6ERME CONSTRUCnON �'– j � CARRIER �` ��� PLAN REVIEW � Z POLICVNUMB[R_ �� � . � ! - E�C��C � Q ^� ! W (n+ssEcnp.ir�Horesop�r�ocn�pErawrsFrna�Mr�a�n � i.yFs} PLUMBINC, / � � 1 CEflTIfYTHAi IN THE PERFORMANCE OF hIE WORK FOR WHICH THIS PERMIT IS ISSUED,( MECHANlCAL y+��������� SHNL NO�ENPLOY ANY PEFSON IN ANY MANNER SO A$TO 6ECOME SUB.)ECT TO 7HE � � WORKERS'COMPENSATbNUW50�CALIFDitYI/SANOA�REETHATIFIS BECO �NSPECTIONFEE r S SU&IECTTOTHEWOflKEHS'CAMPENSATIONPPOVI SOF CT�J37 TME R ISSUANGE /�J � � E,I I�LLiORTHWI7HCONPLYWIiHTHO P IS �+7� p DA7E:�� APPLICANT. __yR����� � '�v� SM1P `1 V � ENERGY P/C J W3pWNf3:FAlUtRETOSEIXIREKORKERS"C041�ENSATqNCOVEpAGEISUNLANM1IlL,ANDSHALLBE � SUBJECTAP7 EMPLOYEfl TO CRN�IM�L PENALTIES AND CN!LflNES UP TOONE HUNDRED TNIXISAN� ENERGY PERMIT OOItARS(St00,aao),IN ADbIT10N TO T!{E C95T OF COMPENSRTXMd.�AMAG£S AS PflOViD£D FOR IN � SECTIDN3�OBOFTHEU80flCWE,MI7EREST,ANOATfORNENSFEES. R�'{�NTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IMEPEBYAFFIqMUNDERPENN.ttOFPERJURYTH�TTHEREISACONSTPUCTIONLENDINGAGENCY Z iOq THE oER W RMMICE OF THE WORK WA WMCN TM�S 7ENMIT IS ISSUED(SEC.30W,CIV.CJ. W � I�NpEA'S NAME F— LENDER'SADDRESS ¢ ICERTIFYTHATIMAVEREADTMISAPPLICqTIONAND5IATETHATTHE/�BOVEWFORMATIONISCORRECL TOTAL FEES � I A�REE TO COMPIV VATH KL�'AND CdUNTV OR0INANCES AN�STRTE UN�S REUTIN6 TO BUILDING CONSTRUCTION,IWD HEREBYAUTT10flIZE REPRESENTATIVES OF TFIIS COUNTV TO ENTER UPON THE Z �80VE�FENTKKJED PflOPERTY FOR INSPECTION PURPOSES. 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