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HomeMy WebLinkAbout10028 (5) CTfY OF DIAMOND BAR "n COMMUNITY DEVELOPMENT DEPARTMENT � /�,- � 2166o E.Coplcy Drive Suite 190 PRESS (909)866-3195 Fax(909)R61-311� RUILDING PERMITAPPLICATTON FIRMLY � N JOBSITE APPLICATION PERMIT PIC a ADDRESS���S ��C'N�L��� DATE NUMBER��" " " " N � ISSUE� TYPE OCC APN LOT TflACT_ DATE CONST. GROUP p OWNER O s " AODRE S ZONING SET6ACKS � CITY ''�rs ZI P TELI.�S'- _3ilS' FRONT RW 0 APPLICANT �, REAR ❑ SIDEISIDE STREET RW O � CONTRACTOR � SIDE ❑ � ADORESS pROPOSED USE � CITY ZIP TEL. "f � o ARCH/ENG/ �z DESIGNER NO.DWEL NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ApJ.AREANALUATION � � � ONMER-BI:ILDER DECLAFtATtON SFWADD/REM 0 � I HEREBY AFFlFW IKJ�ER PEIULTV OF VERJUPY 7HAT I MI E7(EMPT F{�M TME CONTAACT00.S LI- +�f8���rt W CENSELAWFORhIEFOILOWM6flEA90N(SEC.7031.SBUfiINE39ANOPFOFESSIONSCODE:ANYCITYOR (n - U COUNiYWlIIQIRC-0UIRESAPEWMTTOCONSTRUCT,ALiE0.1Y7ROVE,DEI�OLISH.ONREP4RNiYSTRUC- W P8�70/DBCX WNqE,PqqR TO ITS ISSUMICE,N.SO REW�NES TIE APP�ICAM FOR SUdi PEitl.11T TO FILE A SI(aYYEO � S7ATEYENT THAT HE OR SHE IS LICENSED PURSUANT TO iHE PROVISIONS Of 7NE CONiAAc70qs U- � CENSE LAW(o/AP7EH Y(COYYENCW(i WIiH SECTION 1000)OF OIV15pN 3 OF THE BUSlNE55 AND PRO � POOY$p9 Ff55qN9 ODD�Ofl THAT HE OR SHE IS EXEV PT THEREFROM AND TtfE B�616 F-0R7HE ALLEOED EXEYP- V TKkI.ANYVI0LAT10NOF5ECT10NTa31.58Y/�NY�PPIICAMGORAPER4tIT511BJECTST}fEAPPLICNiTTO � Rp-Rppf � A CML PEw�LTV OF NOT M�E 7MM1 FIYE FiUrDREO DOLUAS(SBoo).i: � OI,ASOWNEROFTHEPROPER7V,OqMYELIPLOVEESWITHWAGE3ASTNEIqSOLECOMPENSATqN, 0 �mmercial Wlll DO iHE V�RK.IINO iT1E STRUCNRE IS NOT MRENDEO OR OFfERED FOR S�LE(SEC.70N,6U51• J NE55 AND PRDFESSIONS CODE:THE CONTMCTORS UCENSE UW DOES NOT APPLY TO AN OWNER OF � PHDPERTYNMOBUNffiOHAiYROVF57NEREON.ANOY1Ri000ES6UC1iWURKHIMSEIF�iHERSELFOq � � TtY10UGM HIS OH HER OMM EMPLOVEES,PROVIDED THAT SUCH IMPFlOVEMIEMS ARE NOT WTENDED Oii m QOFFEi�DFOHSALEIF,FIOWEVERTMEBUILDWGOHMPHOVEMENTiSSq.DWI7/i1NONEVEANOFCOYPI.E- � TION,T11E OWNER-BUI�pER WILL h1�VE TME BURDEN OF PflWING THAT HE 01i SNE Di0 NOT BUILD Oq � MIPRDVEFORTMEPURPOSEOFSILE). ❑1,AS OWNER OF THE PROPERT�:AM E%ClUS�VELY CONTMCTdVO WfTM LICENSED CONTRACTORS � TO CONSTRUCT THE WIDJECT(SEC.70N,BUSINESS AND PROFE3410N3 CODE:THE OONiNACTOR6 LI- V81U9�WI1 ADJ.AREA W CENSEIAWDQESNOTAPPLYTOANONMEflOFAPROPER7YWMO8UIL0.50RWPROVESiMEREON.ANO � K1qQONiMCT9f-0p3UCHOROJECTSWITHACONTRACTOR{5)LICENSEDPURSUANTTOTHECONTRAG Q�q�Ty DESCRIPTION FEE � T00.5UCENSELAW.). .}. �/ Q 0 1 MI E%EMCT UNDER SEC. B.L P.C.Fdi THIS REASON v 1_ 7 f�� � � ¢ 7�'��/ S'.',• -�S' Z D�TE OWNEH w �+ u `3"�� l^� / �Q LICENSED CONTRACTORS DECLARATION W �i. j�f /G� � � CC I XEREBV AFFlRM INtlDER PENI�LTY OF PEf WRY TNAT I MM LICENSED UAEF PROVISION3 OF CM�PTER � � Z�o M S � Y(ppyyENCwO WRH 5EC7pN 70�D)OF DM61p�!3 0F TME BUSINESS AND 7POFESSIONS CODE,MD � il� MY L�EMSE IS IN fULL FORCE AND EFFEC7. m ' � '^ {�r !f / 4 Q IICENSE CUSS �^� 7V LIC.NO. � j � c�' /3� VDniE GONTM � � yS � W yd. � WORKERS'COMPENSATION DECLARATION a � �j� � �y, t.u � I NEHEBY AFfiRM UIHIER PENALTY OF OERJUHY ONE OF THE FOLIOWINO DECUMTKKi3: � �n z �L. �- �S � _IMAVEANDNnLLNIUNiAM1ACFRTIFICATE�WNSENTTOSELF-INSUREfURYVOPICERS' � p COMIPENSATION.ASPROVIDEOBYSECTION37000FiMEUBORCODE,FORTHEGERWRMANCE U �� OF THE WORK FOR VMICH THIS PERMIT IS ISSUED. � }f 0 W �t HAVE M�N7LL M+11HTA�N WORKERS'COMPENS/1TKK1 INSUfUNGE,AS REWIKED BY SECTqN � 97000F iHE LABOR CODE,FOR THE PEPFDRMPNCE Of THE WOFUC Wfl WHIQi THIS YERIMT IS 199VED.MV�FiS'COMPENSATION INSURANCE�C.AJq�ER ANO PIX.ICYNUMBER�RE: CONSTRUCTI�I -n � CMiRIER /� NN'"' PUIN HEVIEW '?'..'° ti '7 ;r'�r � ,� o pa�cY�R� 7 � �$� ELECTRIC �.. � (naSSEcrn��wr�m,aFrmoFn��re�rtsr�orveru�oaw�sR+mlaruEss4 PlUM81NG �G'J• Z Z ICERTIfYTH�TINTHEPEHf-0iW�NCEOFTHEN�OP.KFORWHH:HTH�SPERMITISISSUED,I MECHANICAL C7 SHAILNOTEMPLDYANVPEP50NN1ANYMANNERSOAST08ECOMESUB.�ECTiOTNE [n WOHKERSCOMPENSATIONUWSOfCALIFONNI�,MAAGPEETNATIFISNOULDBECOME INSPECTIONFEE SUBJECTTOTHEWORKEHS'COIAPENSATqNPROVISKKJSOFSECTqN37000F7HEU80R �SSUANCE �S�~+ OOOOE.ISMKLF�RIMYITHC01IPlYY1lMiHOSEPImVI510N5. p pATE: APRICANT,G�/lRi�4' ��YD�/� SMIP � ENERGY P/C WNWNO:FARURE TO SEWPE'A�ORKERB'CdAPEN3ATqN COVERAOE IS UNLAWFIIL,AND SHALL 0E LL SUBJECfANE11PLOYER70CRIMMALPENALTIESANDCMLFINESUPTOONEHUNDRE0T110U8AND ENERGYPERNNT DOtLANS(S7oo,oao).B!ADDITION TO TME COSTOF COAIPENSATION,DMUGES AS PROVIOEO FOR IN ¢ SECTpN370lOFTHELABOHCODE.MTEREST,MlDATTORNE�"&FEES. 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