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HomeMy WebLinkAbout16781 (26) CITX OF DIAMOND BAR �'""'"�"—"'� ----� '�`----1 DEPAId.TNT1YIENT OF COMMiJN1TY&DEVELOPMENT SERVICES Q_ :,,� 21825 E.Copley Ihive (909)860-3195 Fax(909)861-3117 PRES$ '�'�.��� BUILDING PERMIT APPLICATION • FIRMLY � JOBSITE � � APPLICATION� ���I{ PERMIT �`'� P/C o ADDRESS DATE f�1.�N NUMBER ' d o ISSUE a d� TYPE OCC APN LOT TRACT DATE �y � u �I�' � CONST. GROUP p OWNER � �- o ADDRE«S ZONING SETBACKS oCI ZIP TELQ � FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ z ¢ CONTRACTO � T� SIDE ❑ �, ADDRE�S P P S U E � CITY ZIP TEL. /� S O��� o ARCWENG! �z DESIGNER NO.DWEL. NO. � NO. 01.'. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. m cr� �ESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION �� p� OWNER-BUILDER DECLARATION SFR/ADDIREM O I HEREBY AFFIHM UNDER PENALiV OF P'cRJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8�89B/CB�Of[ W CENSELAWFORTHEFOLLOWMGREASON(SEC.7031.SBUSINESSANJPROFESSIONSCODE:ANYqTYOfl (f� � C.)� COUNTYWHICHREQUIRESAPERMITTOCIXJSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIFANYSTRUG W Patio/Deck w� � TURE,PRIOp TO ITS ISSUANCE,ALSO RE�I:IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANi TO 7HE PPOVISIDNS OF THE CONTRACTORS LI� � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AN�PRO- LL PDOUSpe FESSIONSCOD�ORTHATHEOR$HEISEXEMPTTHEflEFROMAN�THEBASISFORTHEALLEG�E%EMP- � � � TION.ANVVIOLATIONOFSECTION7o31.58YANVAPPLICANTFORAPERMITSUOJECTSTHEAPPLICANTTO z Re-Rooi �A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLL4R5(ESoo).): ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHYJ.4GESASTHEIRSOLECAMPENSATION, Q Z � Commercial - � WILI DO THE WORK,AND THE STRUCTURE IS NOT M7ENDED 6R OFFERE�FOR SALE(SEG.7044,BU51- J � NE55 ANO PROFESSIONS CO�E:THE COfJiFACTORS LICENSE lAW OOES NOTAPPLY TO AN OWNER OF � ,PHOPERTY WFIO BUIL�S OR IMPROVES THEFEON.AN�WHO DOES SUCH WORK HIMSELF OR HERSELF OR �" THFOUGHHISORHEflOWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m ' QOFFEREDFORSALE.IF,HOWEVER,THEBUIL�INGORIAAPROVEMENTISSOLOWITHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUIL�ER WILL HAVE iHE BUflOEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPflOVE FORTHE PUFPOSE OF SALE�. W ❑I.ASOWNEROFTHEPpOPERTY,AMEXGLUSNELYCONTRACTINGWiTHLICENSEDCONTAACTOftS Q TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AN�PROFESSIONS COOE:THE CONTRACTORS LI- VdIU2I1011 ADJ.AFEA W CENSEUIWDOESNOTAPPLYTOANOWNEROFAPROPER"fYWHOBUILD50RIMPROVESTHEREON,AND — �. WHOCONTRACTSFORSUCHPROJECTSWiTHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTFAC- QUANTITY DESCRIPTION FEE - Y TORS LICENSE LAW.J. �� ❑IAM E%EMPT UNDER SEC, B.&P.C.FORTHIS REASON Q � U LL � DATE OWNER � z w ¢ LICENSED CONTRACTORS DECLARATION W 1L IHEREBYAFFlRMUN�ERPENALTYOFPERJURYTHATIAMLICENSEOUNDERPROVISIONSOFCHAPTER � d 9�COMMENCINOWITHSECTION700o)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z X. MY LICENSE IS IN FL1Ll FORCEAND EFFECi. .r/ �/ ' 0 LICENSE CLASS� LIC.NO.�/�j /Y� � `.� J V DATE[]_[�u� CONTRACTOR a W C �� WORKERS'COMPENSATION DECLARATION Q � I HEREBY AFFIRM UNDER PENALN OF PEfiJURY ONE OFTHE FOLLOWING DEC!ARATIONS: Z Z _tHAVEANDWILLMAINTAINACERT�FlCATEOFCONSENTTOSELF-INSUREFORWORKEPS' _ Q CAMPENSATION,ASPROVI�EDBVSECTION37ooOFTHELABORCODE,FORTHEPERFORMANCE W OF7HE WORK FOR WHICH THIS�PERMIT IS ISSUED. � � � _I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIftED BY SECTION {�q}''''. Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE CFTHE WORK FOR WHiCH THIS PERMIT 15 � l��r �,� ISSUED.MYWO ERS'COMPENSATIONINSURANCECAHRIEflAN�POLICYNUMBERARE: CONSTRUCTION t ��✓ J y CARRIEFi PLAN REVIEW Z aoucvNUMeEa ELECTRIC ¢ � (iH15SECIKKJNEmNQTBEOJMREfE00FlHEPERMfTISFOflIXJEH NDRE��OLLARS�ytO�ORLE55). PLUMBING � I CERTIFV THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (.'} SHALLNOTEMPl.OYANYPERSONINANVfdANNERSOASTOBECOMcSUBJECTTOTHE Uj WOflKEFS'CON�PENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHGUIOBECOME INSPECTIONFEE � SUBJECTiOTHEWOHKEF75'COMPENSATIONPROVISION30FSECTION3�ooOFTHELA80R --�,�j,'iyy � � CO�E,ISHALLFORTHWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCE � � SMIP � p DATE: APPLIdANT � J WARNING FAILURE TO SECURE WOFKERS'COMPENSATION GOVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C � SUeJECTANEMPLOVERTOCNIMINALPENALTIESANDCIVILFINESUPTOONEHUN�REDTHOUSAN� ENERGYPERMIT DOILARS(51ao.oCU),IN AODITION TO THE COSiOF COMPENSATION,DAMAGES AS PFOVIDED FOR IN � d �� � SECTION 37oe OFTHE LABOR COQE,MTEREST,ANDATTORNEY'S FEES. RETENTION FEE: � � CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: � � IHEREBVAFFIRMUNOERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONLENDWGAGENCY FOR7HE PERFORMANCE DF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.CJ. Z lLJ � LENDER'S NAME F=— LENOER'SADDRESS � TOTAL FEES ���, C� w ICEFTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEABOVEINFDRMAilONISCORRECT. �. I AGREE TO COMPLV WIiH ALL CITV AN�COUNTV OROINANCES AND STATE LAWS RELATING TO BUIL�ING �i CONSTRUC710N,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOEM'ERUPONTHE Z ABOVE-MENTIONE�PF,iOPERiY FOR INSPECTION PVRPOSES. COMMENTS � ����;�� J � m PERMI7TEE NAME(PRIN) �C I T- "-' -��`z---��-� - -- � SIGNATURE OF PEP EE �ATE ,r} = RECPT.NO. 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