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HomeMy WebLinkAbout10097 (5) C1TY OF DIAMQND BAR COMMUNITY DEVELOPMENT DEPARTMENT � ..,..� 21660 E.Copley Drive Suite 190 PRESS (909)86Q3195 Faz(909)861-3117 "^" BUILDING PERMTT APPLICATION FIRMLY � ADDR SS�O�Z�Ll� �� /�� /✓��� DATE�ATION 1 /NU BER � �� � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER GG R Q qp�q� ' �/ ZONING SETBACKS gCITY`d f/7�l'iL ZI TEIo� FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDElSIDE STREET RW ❑ CONTRACTOR S� � � ADDRE,jSS � PROPOSED U � CITY ' ZIP TEL����c� � pARCFUENG/ w DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. cn �n DESCRIPTION SQ.Ff. FACTOR PSF ADJ.ARE{WALU/�TION � OWNER-BL;ILDER DECLARATION $FR/qp0lFlEM O � 1 NEREBV AFFlRY UNDER PENAITV OF PERJURV TNA71 AM EXFAIPT FROH THE CONTqACTORS�I- GefBQB/C8IPOII W CENSEUWFORTHEFOLLOM�NOREASON(SEC.7031.SBUSINE6SANDPf�FE5510N5CODEANYCI7YOR (n U WUNTYWHICHREOUtHESAPERAAITNWNSTqUCT,RLTER��R��E,DEMOLISM,ORREPAtRAN1'STRUC- W P8�10/DBCk Z TUAE.PRNkI TO ITS ISSUMICE.AL50 NEIX11RE5 THE APPLICANT FOR SUCH PEPo/IT TO FILE A 51ONED W STIITEMENT THAYHE OR SNE IS LICENSED PURSUAHT TO THE PROVISIONS OF THE CONTRACTORS LI- W � CENSE UW(GIAPTEH 9(C01111ENdNQ WITM SEGTION 7000)OF DIVISION 3 OF TMF BUSINE55 ANU PRO- � PooUSpa FESSIONSODDE)OHTYUI7HEORSHEISEXEMPT7HEREFROl1ANDTHEBASISFORTHEAL1E0E0EXEAIP• C7 V TION.ANVVIOLAT�ONOFSECT�ON7037.SBYANVAPPLICANTFORAPEPMITSU&IECTSTHEAPPLICANTTO Z Re-Roof A CMl PEWLLT'OF NOT MOHE�N FNE HUNDRED DOLLARS(i600�.): �~ ❑I.A50NMEAOFTHEPROPER7Y.ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATIaJ, � Commercial WIU DO THE WOFK,AND THE STRUCTURE IS NOT INTENDED OR OFGERED GOH SALF(SEC.70U,BU54 J N NESS M'O 7RDFESSlONS CODE THE CONTMCTOfl3lICENSE UW OOES NOT APPLY TO AN OMRIER OP � PflOPENfY WI108UILD3OR IMPROVES THEPEON,MID WHO DOES SUQi WORK HIMSELF ON HERSELF OR z Q THFd)GHH45ONHEROWNEYPLOYEES,CPOVIOEOTHATSUCHIYPROVENEMSAPENOTINTENOFDOR m QOFFEflEDWRSALEIF,/bWEYERTMEBUpDWGOFMIPROVEMEMI550LDWR1i1NONEYEI4ROFCfUAPLE Z TION,TME OWNER-BUILDEN VALL HAVE TNE BUfiDEN OF PROVING TNAT HE OR SME UID NOT BUILD OR � 111PRDYE FOR THE PURROSE Oi SALE). W ❑I,ASOWNEROFTHEP90PER'TV,AMEXCLUSNELYCOMRACTINOWI7HLICENSEOCONiMCTOR3 ¢ TO CONSTRUCT iHE PROJECT(SEC.7a14,BVSINE55 MID PROFESSIONS GO�E:hIE WNTPACTOPS L4 V81118I1011 ADJ.AREA LLl CEM1LSEIAWOOESNOTAPPLYTOANONMEHOfAPROPERTYWFIOBUIL�50RIMPpOVE5T1/EFEdG1.AND � NRIOCONTMCTSFORSUdIPROJECTSNI7HACONTMCTOR(S)LICENSEDPURSUANTTOTHECONTRAG �A�TM DESCRIPTION FEE � TaiS LICENSE LAW.). _ ❑IAM EXEMPT UNDER SEC. 8.t C.C.FOP THIS REASON a I O V ti.. @ ' �2� DATE OWNEF U � W � UCENSED CONTRACTORS OECLARATION W � � I IiEREBY AfFIRM UNDER PENAITY OF VERIURY THA7 i AM LICENSEO UNDEq PROVISqNS OF CHAVTER � (`y Y�C04YENCINGWI7HSECTION70oDjOGDIV151ON�OFTHEBt1SMESSANODROFESSIONSCODE,AND Z �C MY IICENSE IS Ml FU.L (1RCE AND EFFECT. � 1����� ��I f � uc�c �uc.nro. � V DATE l % cONTRACTOR L � � WORKERS'C041PENSATION OECLARATION��X/ a /�— , /'��.�. � y IMEREBYAFFINMUNDERPENALTYOFVERtt1RYONEOFTiEFOLLOVANGDECUR7ITIONS.a,O/ 7r Z ���, ! ,�j'� �� � IHAVEANDN�LLMAM1TAnlACERTIflCATEOFCONSENTTOSELF-�NSUREFOflWORKER5 = COMPENSATION,ASCROVIOE�BYSEC710N37000FTHELABOfiCOOE,FOflTHEPEHFORM/NCE �U _ OF TME WOfiK FOH YMiCN TH15 PERM1T131S5UED. � - 0 � _IH�VEANDWILLMAINTAMWOPo(ERS'COYPENSATIONINSURANCE,ASREOUiqEDBVSECTION Q 37000F THE UBaiCODF.FOR7T7E PERfOHMANCE OF THE RK FOH WMtp7 THIS PERYIT IS I5SUED.AIY KERS'COidPE'fy�TION�N M10E CAR APID PoIICY NUMBER ARE� CONSTRUCTION d � � CARRIER�y���l�'I-�L� �LJ PLAN REVIEW � ra�cr�ur.�ER ��L�7 `��C ELECTRIC d � (MssEcf10qt1E�NOTeEm6�REf�oFnEPERJisPIXia�M1�DF+IDDai/RSMooIORLE551 _ MBlNG i Z ICERTIFYTHATNTHEPERFORIIANCEOFiHEN'OiU(FOfiWHICHTNISPERMITI5155UED,l MECHANICAL � (} SNALL NOT FHPLOV ANY PEHSON IN�NY M WNEH SO AS TO BECOME SUBJECT TO TNE (q NqRKERS'fANPENSAT�dJLAw50FCAL�FORNl0.u'1DAOREETHATIFISFqULDBECOME INSPECTIONFEE = SUBJECT TO iHE WORKERS'COMPENSATKKJ PROVIS1GNS OF SEC71ON 77000F 7HE L180R coo i ALL COMPLVwf7HTHOSE�1174isaNs. ISSUANCE � O DATE: I� `� APPLICANT�YlsCitsi'a��4��^ SMIP � � � WApMNo:FAILURETOSECUREWORI(ERS'COMPENS�TIOMCOVEMGEISUNUWFUL.1INDSHALLBE ENERGYP/C �}� LL SUBJECTANEMPIOYERTOCRININALVENALTIESANDCMLFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ��_ ]yO� T, OOLURS(�100,Wo),W PDDITION TOTiE GOST OF COMPENSATION,OAMAGES AS PROVIDW FOR IN j T!3 � SECTION 97oe OF 1HE LABOR CO�E.iN7FNE3T,ANDATTORNEV'3 FEES. RETENTION FEE: d CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O � IHEREBYAFFIR4IN�WERVENAITYOFPERJURYTHATTHEfiEISACONSTRUCiIONLENDIN�AGENCY fOR THE PERW iwM10E OF lHE WOPo(FOR NM1IICiI TH�S PEH►!T IS ISSUED(SEG 3oB7.CIV C.). � . . � IE�WER'SNAME � LENDER'S ADDRE55 W I CEpTIFY Tl11R 1 iUVE flEAO TMI511PPLICATION AND STATE TMAT THE hBOVE INFORMIITION IS CORRECT. TOTAL FE ES ��� � 1 AOHEE TO C0IAPLY NA7H ALL CITY AND CIXINTY OPWNANCES M!0 STATE LANS RELATING TO BUIL�ING �J �� � COHSTRUCTION,ANDHEREBVAUTHORIZEREPRESEN7A71VESOFTHISCOUNTYTOENTEHUPONTHE A80YE•MENTqNED PfiOPERTY FOR INSPECiION PURPOSES. 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