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HomeMy WebLinkAbout16877 (23) CITY OF DIAMOND BAR .�°°""��� ._ --—�`--- DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES �✓� � I � - 21825 E.Copley Drive � (909)860-3195 Fax(904}861-3117 0' _ PRESS `"'-.9»�'�" Bi3ILDING PERIIZIT APPLICATION FI LY a ADDRIESS_ ��� � �'�� "�7 ���� APPLICATION PERMIT � P!C o DATE NUMBER l � ISSUE (�, TYPE OCC APN LOT TRACT DATE l.' CONST. GROUP p OWNER /�12. f�I�-I p ADDRES �-'C )�C. ZONING SETBACKS z CITY Z�p @[, �r �r�/ FRONT RW ❑ o APPLICANT EL. S DE/SIDE STREET RW ❑� m CONTRACTOR �U��� L/Gi_ .�'['!/��r!'l�l"wr�'.�7 SIDE ❑ � ADDRESS �'� o CI ZIP L. >� '�-s PROPOSED USE o ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a AD�RESS � CITY ZIP TE�. UNITS STORIE5 BEDROOMS cn — cn �ESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION p� � OWNER-BUILDER�ECLARATION SFR/ADD/REM �� O p 1 HER�V AFFIRM UNDER PENALTV OF PERJURV THA7 I AM EXEMPT FROM THE CONiRACTORS LI- G8f8JE/C3fPOf[ W CENSELAWFORTHEFOLLOWINGREASON(SEC.7a3f.58U5WE5SANDPROFES510NSCODE:ANYCITYOR (n U COUNTYWHICHRE�UIfiESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORFIEPAIFANYSTRUC- W P81i0/DBCK w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES iHE APPLICANT FOR SL1CH PERMIT TO FILE A SIGNE� w � STATEMENT THAT HE OR SHE IS EICENSE�PURSUANT TO THE PROVISIONS OF THE CONiRACTORS LI- � �. CENSE LAW(CHAPTER 9(COMMENCING WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PRO- POOUSpe . FESSIONSCO�E)ORTHATHE�R$HEISEXEMPTTHEREFROMAN�THEBASISFOFTHEALLEGE�E%EMP- (� � 'TION.ANYVIOLATIONOFSECTION7o31.5BVANVAPPLICANTFORAPEpMITSUBJECTSTHEAPPLICANTTO Z Re-Roof �� ACIYILPENALNOFNOTMORETHAN�FIVEHUNDREDDOLLARS(SSaa�.): �, ❑I,A$OWryEROFTHEPROPERTY,ORMVEMPLOYEESWITHNJAGESASTHEIRSOLECOMPENSATION, COfflRlefC18I ' WILL Dd THE WORK,AND THE STRUCTURc IS NOT INTENDED OR OFFEFED FOP SALE(SEC.7044,8U51- � �; .NE55AN0 PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLYTO AN OWNER OF = �.PROpERTY WHO 9UILDS OR IMPROVES THEREON,AN�WHO DOES SUCH VJO(iK HIMSELF OF HEASELF OR �', �THFiOUGHHI50RHEROWNEMPLOYEES,PROVIDEOTHATSIJCHIMPROVEMENTSARENOTINTENDE�OR m ' Q; �FFEREOFOqSALE.IF,HOWEVER,�THEBUIL�INGORIMPROVEMENTiSSOLDWITHINONEYEAROFCOMPLE- Z,,, ,TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OP �� �IMPROVE FOR THE PURPOSE OF SAIEJ. �y,�� ❑4RSOWNEROFTHEPflOPEFYtY,AMEXCWSNELYCONiRAGTINGWITHLICEN5EDCONTFACTORS ��, TO CONSTRUCT hIE PROJECi(SEC.�044,BUSINESS AND PflOFESSIONS CODE:THE WNTRACTORS LI- VaIU2llOf1 ADJ.AREA W� CENSEU+WODESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTiiEREON,AND � WHOCONTRACTSFORSUCHPFOJECTSWITHACONiRACTOR(S)LICENSEOPUR5UANTTOTHECONiRAG QUANTITY DESCRIPTION FEE � Y TORS LICENSE LAW.�. Q Q �� ❑I AM EXEMPT UNDER SEC.'� B.6 P.C.rORTHiS REASON ' LL OATE OWNER f— �� � C � W �, LICEN$ED CONTRACTORS DECLARATiON W ¢ EG'�. 1 HERE6YAFFIRM UNDER PENAITY OF PERJURV THAT I AM LICENSEO 11NDER PROVISIONS OF CHAPTEP � � a„ 9tCOMMENCINaWtTHSECTION7000)OFDIVISION30FTHE6USINESSANDPROFESSIONSCODE,AND Z X��' MY LICQJSE IS IN FULL FORCEAND EFFECTr.� �,s �'. LICENSE CLASS �P��� ��—s LIC.NO. � � / � U DATE � � CONTRAC70R ��L�b!�_r�tr� a W � WORKERS'COMPENSATION DECLARATION ¢ ��. I HEREBY AFFIRM UN�ER PENALTW OF PERJURY ONE OPTHE FOLLOWMG DECLARA710N5: z /� /' .I� � � Q 6 4� l�P �� _IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q COMPENSATION,ASPflOVIOE�BYSECTION370oOFTHELABORCO�E,FORTHEPERFORMANCE W Q OF THE WORK FOR WHICH THIS PERMIT IS ISSl1ED. � W �✓ I HAVE AND WILI MAINTAIN WORKERS'COMPENSAiION INSURANCE,AS RE�VIRED BY SECTION Q� 37000FTHELABORCOD�,FORTHEPERFORMANCEOFTHEWORKFORVJFiICHTHISPERMITIS ISSUED.MYWORNERS'COMPENSATIONINSURANCECARRIER NOPOLICYNUMBERARE: CONSTRUCTION ¢ S,"?��'�3'� �u.v``.�� - > cnqaiEa� PLAN REVIEW } Z POLICYNUMBER �'��(,�,�{'�� F/s� ELECTRIC ° c / Q Q (iHISSECTKJNNEmNOTB�OJMPLEfEDOFIHEPERMfTISWRONEHUNDRE�COLLAR5�y10�ORLE55). PLUMBING Z I CERTIFV THAT IN7HE PERFORMANCE OFTHE WOPoC FOP WHICH THIS PERMIT IS ISSUED,1 MECHANICAL C,� SHALL NOT EMPLOYANY PERSON IN ANV MANNER SOAS 70 BECOME Sl/BJECT TO THE � � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THATIF I SHOULO BECOME INSPECTION FEE F SUBJECTTOTHEWOFKERS'COM?ENSATIONPROVISIONSCF CTIflN3�ooOFTHELA80F � COsyDE SH L FORTHWITIIGOMPLYWITHTHOSe ��VISION� ISSUANCE . ✓'" � [���. SMIP p� DATE: � ApPLICANT_ J WARNING:FAILUREiOSECUflEYWRKEflS'COMPENSATIONCOVE EIS LAWFUL,AN�SHPLLBE ENERGYP/C ' .� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCNILFINESUP NEHUNDREDTHOUSANO ENERGYPERMIT DOLLARS(S7CO,D00),IN A��I710N TO THE COSTOF COMPENSATIDN,DAMAGESAS PROVIDED FOR IN .�J� SECTION 37oe OFTHE LABOR COQE,INTERESL ANDATTOfiNEY'S FEES. , � REiENTION FEE: � � � CONSTRUCTION LENDIN6 AGENCY PRE-ALT FEE: � IHEREBYAFFlRMUNDERPENALT�'OFPERJURYTHATTHEREISACONSTFUCTIONLENDWGAGENCY Z FOR THE PERFOPMANCE DF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.). . LLJ S LENDER'S NAME � �i _'__ Fr LENDER'SAD�flESS � TOTALFEES �\ � I CERTIFY THAT I HAVE REA�THIS APPLICAiION AN�STATE THAT THE ABOVE INFOflMAiION IS CORRECT � �� �'°'d 11 � IAGREFTOCOMPLVWITHALLCI7YAN�COUNTVOPOINANCESANOSTATELAWSRELATMGTOBUILOING ' �� ` � � CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OFTHIS COUNTV TO ENTEFUPONTHE Z ABOVE-MENTIONEDPROPERTVFORINSPECTIONPURPOSES. COMMENTS � ��,v/ / �f � m� PERMITTEENAME T; e � �/� � � , N SIGNATURE EE DAiE � �= RECPT.NO. �' PAID BY VALIDATION ~ .. WHITE—Deoariment Co YELLOW—Finance Co PINK—Assessor Co GOLDENRO�File Co GREEN—A IicanYs �o PY� PY� PY� PY� PP PY . , , _ ,� �_ ..ti � , �„ .� . ..,.� :-- ,.,.;; , ,, �,. ' `.�� ,,° , .. ., � . 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