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HomeMy WebLinkAbout10981 (5) CI'I'Y OF DIAMOND BAR �- ; COMMUNITY DEVELOPMENT DEPARTMBIVT ' 21660 E_Copley Drive Snite 190 �� (909)860-3195 Fax(909)R61-3117 PRESS ""°� BUILDINGPERMITAPPLICATION � f FIRML1f oN JOBSITE ( !_�C ���.� D�r,� � APPLiCA 1 N ,�M� PERMIT __� P/C ADDRESS �� ��+ L� DATE_ �-;W Nt/MBER # � ISSUE /� � � TYPE pCC APN �LOT_�_._ TRACT DATE !/������ � CONST. GROUP °C OWNER ' �Ie- S 0 " ADDRES .P PCt , ZONING SETBACKS 0 Z CITY ZI TEL. FRONT RW ❑ � APPIICANT � TEL. REAR ❑ � SIDE/S1DE STREET RW C1 � CONTRACTOR SIDE ❑ Q ADDRESS pROPOSED USE '`���� �d�� ��� � CITY ZIP TEL. o ARCWENG/ Z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � GTY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-SI;ILDER DECIARATION SFWAD�/REM O � 1 NEREBY AFFIRM UN�ER PENCLTY OF PERJURY THAT I AM EXEMPT fROM THE CnNiRACTORS LI- G9fTnR/C3!�01'I V,/ CENSELAWFOfl7HEFOLLOWMGREpSIXJ(SEC.]031.58USINESSANDPROFEccpNS�CE:ANYQ�OR (n U CAUNiVWHICHPEWIRE5A7ERMITTOCONSTRUC7ALTER.IMCROVE,�EAIOLISH,ORREPAIRANYSiRIJC- W patio/Dack Z NHE,PFIOR TO ITe ISSUANCE,PS.SO REQUfRES THE APP�ICANT FOR SUCH PERMIT TO FILE A S!GNED W � SUTEMENT THAT NE OR SHE IS LICENSED PUi1SUANT TO THE PPOV:SIONS OF THE CAN7RACTOPS LL � CENSE lAW(CHAPTER 9(COMMENCMM;WITH SECTION]OOO�OF O�VISION 3 OF THE BUSINE55 AN�PR6 � PooVSpa FESSIONS CODE)OR TNAT HE OR SHE IS EXEMPT THEREFROM ANO THE 9ASIS FOF TNE ALLEGEO E%EMP- TI9N.ANYVfOLAT10NOFSECTION703t.5BVANVAPPLICANTFORqPEflMITSU&IECTSTHEAPPLICANTTO Z Re-Roaf � A CI IL PEN/LLTY OF NOT bbRE THAN FlVE HUNDFiED OOLLAFS(ES��y. � �I7.ASOWNEROfTHEPROPERTY,ORMVEMPLOVEESWI7HWAGESASTHEIR50LECAMPEN5AT10M, O Commerctat Z WILL DO THE WORK,AND THE STRUCTURE IS N�T INTENOEO Ofl OFFEPED FOR SAIE(SEC.7D64,BU51� J � � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � GROPERTY WHO BUIIA3 OR IMPRaVE3 THEREON,AND WHOOOES SUCN WORK NIM5ELF OR HERSELFOH [L TNRWGHHISORHEROWNEMP�OYEES,PROVIDEDTHATSUCHIMPROVEMENTSpRENOTINTENDEDOR m WQ OfFEREUFORSALEfF,HOWEVERTMEHUILDWGORIMPqOVEMEN71550LDWITHINONEYEAROFWMPIE� Z TION.THE OWNER-Bl11LDER WILL HAVE TNE BUflDEN OF PROVING TIiAT HE Ofl SHE OID NOT BUIID OR � IMPROVEFORTHEWRPOSEOFSPLE). ❑I,AS ONMEfl oi T}IE PROPFRTY,AM E%GWSIVELYCONTRACiING WITM LfGEN5E0 CONTRAGTOflS � TD WNSTAIIGT iHE PROJECT(SEC.Ia1l,BUSWE55 AND PROFESSIONS GODE:7ME CON7iL4CTOR5 U- V81118I10� ADJ.AREA W CENSEtAW WESNOTAPPLYTOANOWNEflOFAPROPEflTYWH�0U1L�50RIMPAOVESTH£REOW.AND �2 WMOCONiRACTSFOHSUCNC(ioJECTSWITHACONTRACTOfl(5)LIGENSEDPURSUANTTOTMECONTRAG QUANTITY DESCRiPT1ON FEE r��/-s TORSLICENSELAW.�. "" ❑IAlI E}(EMPT VNOER SEC. 8.h P.C.FOR THIS REASON a � U � LL' OATE �- owraEa V � LICENSED CONTRACTORS DECLAPATION ' W J � 1 HEREBY AFFlRM UNDER PENALTV OF PENURV THA7IAM LICENSED UNDER PROVi510NS OF CNAPTER � � � 9(COMMENCIN�WITH SECTION70ao�OF DiV1510N 30F THEBUSINESS AND PROFESSIONS CODE,ANU z �X MY LICENSE iS IN FULL FORCEAND EFFECT. m � � � LICENSECLASS_ UC.NO. � F J v ppre coNraacroa a w � WORKERS'COMPENSATION DECLARATION Q � i NEREBYAFFlRM UNDCR PENALTV OF PERIURV ONE OFiHE FOILOWING�ECIAFATIONS: U C/S ¢ 0 ___IHPVEAN�WI�LMAINTAIryACERTiFICATEOFfANSENTTOSELF-INSUPEFOHYIOR%EAS' _ � C(MIPENSATION,AS VROVIDED 9V SECTION 3100 aF THE UBOR CO�E,FOR THE�EP WRMANCE IU OF THE W�RK FOR WHICN iHtS PEAMIT IS ISSUED. � 0 W ___I HAVEANO WILLMAINTAIN WOflKEflS'fAMPENSATION INSURANCE.AS REQUIREO BYSECTION �/j � O 97000FTHELABORCWE,FORTNEPERWPMnNCEaFTHEW�RKFOPWHiCHT}115PERMIi15 //(/• ✓� ISStIED.MYN/ORKER$'COMPENSATION INSUftANCE CAqRiER ANp POLICY NUMOERAPE: CONSTRUCT !✓ J j CARRIEfl PIAN FEVIEW � POLICV NLIMBER ELECTPIC Q - 0 (TI-esSEc'r�oMrvEmNo7eENhwtErEDCF'f1-EPERMTISFIXiONENJl�OF7[000luPsgtco�oaLEss). PLUMBING ' W MECHANICA� Z ICEHTIFYTHATIN�PERFORMANCEOFTHEWC%iKFOAWNICMTHISPEPMITI5155UED.l (f SMr1LLNOTEMPLOYANYPER50NINANYMnNnEHSOn5T08EGOMESUBJECTTOTHE (p WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIfISNOULOBECOME � ONFEE _ � �- $VBJ[CTT0T1iEWORKERS'COMPENSA710NPROVISIONSOFSECTION3]ooOFTHEIPbOq � CODE,�SHALLFOHTHWITHCOMPLYWITHTHOSEPROVISIONS. �S N � � SMIP ' � p DATE: APPLICANT p W � ERGY P/C I�� f� J WARNING FAILURE 70 SECUIiE WOHKERS'CAMPENSATION CAVERAGE IS UNLUNFUL,ANO SHAI.lOE � SU&fECTPNEMPIDYEFTOCAIMMALPENALTIESPNOCIVILFINESUP700NEHUNDREDTHOUSAND ENERGYPERMIT WLLAR9(f 100.000),IN ADDITON TO h{E COST OF COMPENSATION,DAMAGES AS PROVIOEO F00.1N � SEGTbN 37oe OF TME UBOR COOE.INTERESi ANDATfORN[V'S FEES. F{�TENTION FEE: d CONSTRUCTION LENOING AGENCY PRE-ALT FEE: _ O �C IHEREBYAFFIPMUNDERPENAITYOFPERJVRYTHATTHEREISACONSTAUCTIdJlEN01NGACENCY �a fORTHE PERFORMANCE aF THE WORK FOfi WHICH THIS PERMR I5155UED(SEC.3097,CIV.C.). lJ.l � LENDER'S NnME i--� LENDEFYS ADOPE55 � TOTAL FEES ��' .....�- w ICERTIFYTHq71HAVEREADTHISAPPLICAiIONAND57ATETHATTHEABOVEINFORMATIONISCORRECT IAGREETOCAMPLYWITHALLCITVANDCOUNTYORDINANCESANOSTATEUWSRELATI4GTOBUtLDINC � � CONSTRUCTION,PNOHEREBYAUTHORIZEREPP[SENTATNESOFTHISCOUNTYTOENTERUI'ONhIE r- / C�A !� znBOYE-NEMbNEOPROPEFiNFORINSPECTIONPURPOSES. GOMMENTS ��� �� ���/� d�� ����� s �L,�� /71�� C�•.�aYCfi.� �.cc55 Tra'Atn/ .�;' � I.�aafQ.�- � PE�EFjJAME(PRINT �� �` "] - ������� ¢ ls'[1 � [ 'eC.�'��� � S�GNATUREOFPERMITTEE OATE z RECPL NO. PAID BY VALI�pSaOtJ _ �"" WHITE—Department Copy.YELLOW—Finance Copy,PlNK—Assessor Copy,GOLDENROP-Fife Copy,GREEN—Applicant's Copy " C�(!� 'n 'n �n ?5 [y fl� Cn Cn O (7 � � Cn �I 77 SJ 77 -n 7� '� -i fn L� m -n Cn mm � -� z � F. � rnrn�� x; rny: xa: oc� ao � o'r � y'`,�� mGi � m'a � `p ..+�L Y � m �9 . -C r_,r."'{ O G C. C O ?' O -i�`-�� O 'U-i � _ �r-�r r y -[a -t i rn <r �;� r' ���. 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