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HomeMy WebLinkAbout10895 � CITY OF DIAMOND BAR 1 � COMMUNTI'Y DEVELOPMENT DEPARTMENT � 21660 E.Copley Drive Suite 790 � pR�f�`C�` (409)860-3195 Fax(909)861-3ll7 ��'+�' BUILDING PERMIT APPLICATION ' FIRMLY � JOBSITE / �!���r �r APPLICATIONl p�RMIT � lCf;w 4 T o ADDf�ESS I(���' !•�""'-� +ti� �� DATE t� .L���',� NUMBER # � J''s'2 O � ISSUE TYPE OCC APN ,/�,�l0T�� TRACT �S�I DATE__ __CONST. GROUP _ � OWNER _��� !^��R � ZONING SETBACKS ADDRESS t�50 �'MCS 8i-� '��'-' CiTY Qi-ha.�JQ A�Q, ZIP TEL.��•��� FRONT RW ❑ z -- APPLICANT_���G E1w/5 TE�. C3.�qT3�/ REAR Ci p SIDE7SIDE STflEET RW ❑_ � CONTRACTOR�_���� r�m� SIDE � Q ADDRESS � ���`�^� PROPOSEDUSE � CIT�`(�_lt++i� ZIP T7/-D TEI. +�d'�`� w ARCHIENGI z DESIGNER �S"r�� NO.DWEL. NO. NO. a ADDRESS �3'3?-- �+�.-s���,�__-_ UNITS STORIES BEDROOMS � cirr�.i��.�, Z1P C��o� TEL.�/�_S�g��c� � DESCRIPTIOtJ SQ.Ff. FACTpR PSF ADJ.AREANALUATION � Q OWNER�BI;IIDER DECIARATION SFR/AD0/REM � !NEREBY AFFIRM UNDEfl PEFIALTY OF PERJUHY THAT I AM EkEMPT FR�M THE CohiNnCToaS Lb u'� �aianplCa'^H � GENSELAWFORTHEFOLLOW'NGREASON{SEC.T03t58U<MESSAN�vR�cccci�Srnn�,�.;yCITYCR L7 LOIiNiYWrilCMfiE�]VIRtSAPEIiMITTOCANSTRUCT,ALTER,iMPPOV�,OEMOLISN,OPREPAIRANYSTFUG PdI10/DBCI( WTUqE,PAIOR 70 iTF ISSUANCE.ALSO REOUIRES 7H�APPLICA4T FDR SUCH PERMIT TO FILE A SIGNED w I _ � SiATEMENT THAY HE aR SHE 19 IlCENSED PURSVANT TO THE aROVI510N5 OF THE CONTRACTCRS U. (,(_ p��VS 3 �J CENSE LAW(CHPPTER 9(CAMMENCING WITH SECTIQN lOaC)�F D�41510N�CF TH[9US:VESS AND PRO- � P �ol '•��' � D� FESSIONS CODE)oq THAT HE OR SHE IS EXEMPT THEREFROM AN�Tf1E BASIS fOR'HEALLEG'e0 E%EMP- - V .TIOt1.ANYVI�LATI0NOF5EC710N7J3�.5BYANYAPPLICANTFOFAPEflMR5U8:ECTS7lIEAPPLICANTTO Z Re-Ro��f A CIVIL PENALTY OF NOT MOftF THAN fIYE NUNORED DOLLARS(f 5 W).j: k Q ❑I.ASOWNEqOFTHEPROPFRT'/,ORMVEMPLOYEESWI'HWAGESASTHEIRSOLECDM°ENS4TION, � COmfil8fCi3� Z WILI W THE WOFlN,AN�TNE STRUCTUflE IS NOT IIv7EN[lED OR OFFERED GOa SALE(SEC.�o4a,BU51� J � NESS ANO 7RO�ESSIONS CC]DE�.TNE CONTRAC7aRS LIGENSE LAW COES NaT APPLY'O AN OWNER OF � PROPERTV WHO BlJ�L05 OR IMPROVES TMEfttON,AND WHO DOES SllCH WORH H!MSEIF OR HEFSEIF CR [t THRWCHHISORHEROWNEMP�O�EES,PROVI�EOiHATSUCHiMVaOVEMENTSl.FEN�TINTENDE�OR � W OFFER£DFORSAIE.IF,HOWEVERT�EBI1'�,LDINGOFIMGROVEMENTISSOIDWIiHiNONEVfPfiOiCCMPLE- � TION,h1E CWN[R-6UI.OER VdILi HAVE THE BURDEN OF PAOVING THAI NE Oli SHE O!�NOT&IILfI OR � IMFflOVE FOR THE PUFIPO6E OF SALE�. � � �71,ASOWNEROFTIiERROPLRTV.PMEXCLUSIVELVCONTPACPNGWITNLICENSEDCCNTRACT�FS �J w Tp CpYSTRUCT TH[PilQiECT�SCC.7osC,BUSINESS AND PROFES510N5 COL1E:THE CONTRACTONS LI- OY � Valuaian 1 ADJ.AREA LU CEN3EUWDOESNOTAPf'LYTOANOW4EROF0.4R09ERTVWH06VItD50RllAPROVESTMEFfON.ANI) � IYHOCONiFACTSFORSUCHPROJECTSWITHACONTPACTOR(S)IICENSEDPURSUANTTOTHECOM17RAt'- QIJANTITY DE RIPTION FEE TOPSUCENSElAW.7. � �� �, �. ❑IAME%EMPTUN�ERSEC,_. _ B.B.P.C.FORTHISREASON Q g c= !`�� �d�G �'.d f .rr u" ORTE ` OWNEP U - � IICENSED CONTRACTORS�ECLARATION � I QI HEREBYPFFlRM UN�ER PENALTV OF PERJURV THAT I AM LIGENSED IINDER PROYISIONS OF CH4oTER /�+ �/� p_ 9(CbAAMENC!NGW�THSECT!ONJCL^)OFDINSION30F'HEBUSINESSANOPROGESS�ONSGODE,ANp � � �'T�� � � M�'(L�CENSEISINF�y.LFORC.EANOEFGECT. � I ����JA � - U � LICENSE CLASS�r� � UG.NO. • 'r g�� ` � 'T � � t.�ri�- 'l� s�!T/��� F J V DATE �I� CONTRAGTOR��.f� d 06 , �ti'OR!(ERS'COMPENSATIONDECLARATtON �rhQ�'�d Q I T�� rJ� �/ �f —r �, � "� v U � IMERE9YAfFlRMUN�E4PENPLTVOFPERJURYONEOFTHEFOLIOWlNGOECLARATiONS: - (A ` Q Z _IHAVEAN�WILLMAINTAINACERTIFICATEOFCONSENTTOSE�F�INSUREFORWORKERS' _ CQMPENSATION.ASPROYIDE78VSECTION3]DOOFTIiE1.A'�ORCODGFORTHEPE(1FOFMANCE U � OFTHEWUHKFOFWNICHTHISPEflMfTI5155UE0. � O W _IHAVEANDWILLMAINTAIryWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION /� a sioo OF THE LABOR CODE.FOR THE PERFOPMANCE OF iHE W09K fOR WHICH THIS PE��MIi IS �Y�, �'� ISSUEO.MYWORKERS'COMPENSATIONINSUAANGECARRIEqANDPOIIGYNUMBERAPE: / CONSTRUCTI � l J ���� s CARRIER �� ._�_`� � P�AN REViEW d `�' �' � C' �� EIECTF 0 POLICYNUMBEF f�/ � j� O R}ASSECf10NNE�NOTBE�IARETEDOFThL-GERMTLSFORIXJEM�PDFPJ (51m�aRlESS). 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