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HomeMy WebLinkAbout17297 (26) CITY OF DIAMOND BAR � � --���°`' - DEPARTMENT OF CO�TY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY yi JOBSITE �a.^� r� APPLICATION PERMIT P/C o�b ADDRESS��zl�S RSI�C�. t'in� �9r+✓L DATE .r�- 2�'/ —f.�,� NUMBER���_9� # �' ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p; OWNER �P/�I��r ��b��. .�Car�ef� ADDRESS Z/ '� A, ja' DA��'✓ ZONING SETBACKS Z�� FRONT q�J�r ❑ CITY ," �o�,r ZIP I' S TEL.� -1Z/3 � APPLICANT TEI.$'���.i REAR ❑ z' SIDE/SIQE STREET RW ❑ ¢ CONTRACTOR „/?'Z SIDE p ADDRESS �'� � CITY ZIP TEL. PRQPOSED USE t'J�� °'�� S�"�Z� K�� _._,.__._...____,,. . � ARCH/ENG/ " /�c"�C.... � z DESIGNER �� "'L��'�� w NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O O I HEFEBY AFFIflM UNDER PENALTY OF PERJUflY THAT 1 AM E%EMPT FROM hiE CONTRACTORS LI� Gafag9/COfpOtt W CENSELAWFORTHEFOLLOWINGREASON�SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTYWHICHREDUIRESAFERMITTOCONSTRUCT,AL7EF.IMPFOVE.DEMOLISH,ORREPAIRANVSTRUC� W TURE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT fOR SUCH PERMRTO FIIE A SIGNED W Patlo/Deck � STATEMENT THAT HE OR SHE LS LICENSED PURSUANT TO THE GROVISIONS OF THE CONTRACTORS LL CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION�000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- � POOVSPe O FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLE6EDEXEMP� (� V TION.ANYVIOLATIONOFS[CTION7031.SBYANVAPP�ICANTFORAPERMITSUBJECTSTHEAPPLICANiTG z Re-Roof � ACIVIL NALTYOFNOTMORETHANFNEHUNDREDDOLlARS(SSoo).)� � �ASOWNEROFTHEPROPERN,OFMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATICN, � COmmefClBl Z WILL O THE WORK,AN�THE S7RVCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.70d4,2USI� J � NESS AND PROFESSIONS CO�E:THE CONTRACTORS UCENSE lAW DOES NOT APPLY TO AN OWNER OF � PROPERTV WHO BUItDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR CC THROUGHHISORHEROWNEMPLOVEES.PROYIDEDTHATSUCHINPROVEMENTSARENOTINTENOEDOR m OOFFEREDFOfiSALEIF,HOWEVER,THEAWLDINGOPIMPROVEMENTISSO�DWITHINONEYFAROFCOMPLE� Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING T4dAT HE OR SHE DID NOT BUiLO OR � IMPROVEFOHTHEPURPOSEOFSALE�. w ❑I,ASOWNEftOFTHEPROPERTV,AME%CLUSNELVCONTRACTINGWITHLICENSEDCANTFACTORS .. [[ TO CONSTRUCT THE PROJECT(SEC.�o4a,BUSINESS AND PROFESSIONS COOE:hIE CONTRACTOFS LI� V 110f1 O _ADJ.AREA W CENSELAW�OESNCTAPPLVTOANOWNEROFAPROPERTYWHOBUIL�SOFIMPROVESTHEREON,AN� -�" � WHOCONTRACTSFORSUCHPR0.IECTSWITHACONTFACTOR(5)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). Q ❑1 AM EAEMPT UNDER SEQ______________—_ _ B.8 P.Q FOR THIS REASON Q ?� U Lt" x R h z W � UCENSED CONTRACTORS DECLARATION W ¢ � IHEREBYAFFIRMUNDERPENA.TYOFPERJURYTHATIAMLICENSEDUN�ERPROVISIONSOFCHAPTER � � 9(COMMENCING WITH SECTION 7oD0)OF DIViS',ON 30F THE BUSINESSANO PROFESSIONS COOE,AND z `X MV LICENSE IS IN FULL FOFiCE AND EFFECT. m � LICENSE CLASS LIC.NO. � H � V DATE CONTRACTOR � W � WORKEFiS'COMPENSATION DECLARATION Q � I HEREBYAFFIRM UNDEF PENALNOF PERJURV ONEOFTHE FOLLOWING DECLARATIONS: z Z _I HAVE AND WILL MAINTAIN A CER7IFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' ¢ 2 ¢ �MPENSATION,ASPqOYIDEDBY5ECT10N37000FTHELABORCODE.FORTHEPEHFORMANGE U Q OFTHE WORK FOR WHICH THIS PERMIT IS'��SSUE�. � w I HAVE AND WILL MAINTAIN WOHNERS'COMPENSATION INSURANCE,AS PEOUIRE�BV SECTION O 3"I00 DF THE LABOR COOE,FOR THE PERFORMANCE OF TFE WORK FOR WH�CH THIS PERMIT IS ���.S� ISSUED.MY YlOFKEFS'COMPENSATION INSURRNCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION J � CARFIEF PLAN REVIEW Z POLICV NUMBER ELECTRIG Q 0 (fHISSEC'•pNNE�NOTBE�OMPLETEDOFT}iEPERMRISFORQVEHUIJ�RE�DJl.L1AS15100)ORIESS). PLUMBING ___._,.,.,- '^y,_._._._._..._. Z I CER7IFY THAT W THE PERFORMANCE OF THE W'ORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL ^-,�� �\ �E�� +'4.�M�,..��} (!3 SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO OECOME SUBJECT 70THE ' " ' "- `" ' "��"�•—�=--" �. � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGFEETHATIFISHOUIDBECOME INSPECTIONFEE � SUBJECTTO THE WORKERS'COMPENSATION PPOVISIONS OF SECTION 3]ooOF TNE LABOP j = GODE,ISHALLFORTHWITHCOMPLVWITHTHOSEPFOVISIONS. �SSUANCE A � p OATE: APPLICAM: SMIP � J WARNINGFAI�URETOSECUREWORKERS'COMPENSATIONCOVERAGEISVNLAWFUL,AN�SHALL9E ENERGYP/C t � SUBJECTAN EMPLOYERTO CR!MINAL PENALTIES AND GIVIL FINES UP TOONE MUNDPED TMOUSAND ENERGY PERMIT DOLLARS(5100,OW�,IN ADDITION TO THE COST OF COMPENSATIO�'.DAMAGES hS PROVIOED FOR IN p� � SECTION37080FTHELABORCODE,M7EREST,ANDATTORNEV'SFEES. RETENTIONFEE: L v� OCONSTRUCTION LENDING AGENCV PFiE-ALT FEE: � 1 HEflEBVAFFIFM UN�ER PENALTYOF PERJURY THAT THERE IS ACONSTRUGTION LENDING AGENCY FORTHE PEFFORMANCE OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.309],CIV.C.�. Z W j IENDER'S NAME � F— IENDER'SAD�RESS � ICEflTIFVTHATIHAV�flEADTHISAPPLICATIONANDSTATLTHATTHfABOVEWFOftMATIONISCORRECT. TOTAL FEES �� w I AOREE TO COMPLV WITH AL'�CITY AND COUNTY ORDINANCES AND STATE UWS REIATING TO BUILOING � � CONSTRUCTION,.4N�HEREBYAUTHORREREPRESE'JTATNESOFTHISCOUNTVTOENTERUPONTHE Z ABOVEMENTIONEO PROPERTY FOR INSPECTION PURPOSES. COMMENTS � Bt T e� m '`P ITTEE NAME(PRIN,� �- � _���i�_�.`v �f� �9 f1 � �I NATUNE OF PERMITTEE OA,E = RECPT.N0. 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