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HomeMy WebLinkAbout16816 (19) CITY OF DIAMOND BAR ---�'�`"'-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I � - 21825 E.Copiey Drive (909)860-3195 Fax(909)861-3117 PRESS '�"%.Y���\' BUILDING PERMIT APPLICATION FI R M LY � JOBSITE �` �. APPLICATION � f,I� �� PERMIT ` � � PIC o ADDRESS���� � ]� � (°�Jq� DATE ! NUMBER � # � ISSUE TYPE OCC APN LO �T`RP�C�T DATE CONST. GROUP p OWNER � C�I o ADDRESS 'E' �`W� ZONING SETBACKS z CITY : t�" ZIP TEL. FRONT RW ❑ p APPLICANT TEL. S DE/SIDE STREET RW ❑ z ¢ CONTRACTOR cr �' ' S SIDE ❑ � CITY C°�1�+� ZIP� TEL. PROPOSED USE � 4 �" o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO. o_ ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS c� ci� DESCRIPTION SQ.FT, FACTOR PSF ADJ,AREANALUATION p� OWNER�BUILDER DEGLARATION SPR/ADD/REM O � I HEflEBY AFFlRM L1N�ER PENPLTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTOflS LI- Gflfd90/C2fpOf[ W CENSELAWFORiHEFOLLOWINGREA50N(SEC.7a31.58U51NES5ANDPROFE5510N5CODE:ANYqTYOR (n C� COUNTYVJHICHREQUIRESAPERMITTOCONSTRUCT,ALTEF,IMPROVE,�EMOUSH,OPREPAIRANYSiRUC- W Patio/Deck z 7URE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIG4ED �W STATEMENT THAT HE OR SHE IS LICENSm PURSUANT TO THE PROVISIONS OP THE CONTRACT�PS u- W CENSE LAW(CHAPTER 9(COAIMENCING WITH SECTION 7aDa)OF�IVISION 3 OF THE BUSINESS AND PRO- �'1' POOUSPd O FESSIONSCODE)ORTHATHEORSHEISEXEMPTTWEREFROMANDTHEBASISFOPTHEALLEGEDEXEMP- (� V TIDN.ANYVIOLATpNOfSECTION7D31.5BVANYAPPLICANTPoRAPERMITSUBJEC75THEAPPJCANiTO Z Re-Faof. A CIVIL PENALTY OF NOT MORE iHAN FIVE HUNDRED DOLLAFiS(S5o0).): Z ❑I,ASOWNEFIOFTHEPFOPERTY,ORMYEMPLOYEESWITN3NAGESASTHEIFSOLCOMPENSATIIXJ, � (,`OfIIfPIEtCiB� -- WILL W THE WORK,AN�THE STRUCTIIRE IS NOT INTENDED OR OFFERE�FOfl SALE(SEC.7044,BUSI- J � NESS AN�PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOi APPLY TO AN OWNEH OF � PROPERTY WHO BUILDS OR IMPROVES THEREON;AND WHO DOES SUCH WORK HIMSELF Dfl HERSELF OR CG THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPFOVEMEMSARENOTINTENOeDOF m Q� OFFEREDFORSAIE.IF,HOWEVER,THEBUIL�INGORIMPROVEMENTISSOL�WI7HINONEYEAROFCOMPLE- Z, TION,THE OWNER-BUILDER WILL HAVE THE BUFbEN OF PROVING THAT HE OR SHE DID NOT BUILO OR = IMPROVE FOR THE PURPOSE OF SALE). w ❑I,ASOWNEROFTHEPROPEftTY,AMEXCLU5IVELYCONTflACTINGWITHLICEN5E0CDNTRACTORS � TO CONSTflUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE',THE COMRACTORS LI- Vflluation �. ADJ.AREA W�. CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVES�THEiiEON,AND � '= WHOCONTRACTSFORSUCHPROJECT5WITHpCONTRACTOR(S)LICENSEDPURSUANTTOTHECONTflAC- QUANTIN DESCRIPTION FEE Y TORS LICENSE LAW.). � ❑I AM EXEMPT UN�EF SEC, B.&P.C.FOR7HI5 REASON Q � U LL � DATE OWNER h' �. W � IiCENSED CONTRACTOFS DECLARATION W ¢ CC I HEREBYAFFIRM UN�ER PENALTY OF PERJURY THAT i AM LICENSE�UNDER PROVISIONS OF CHAPTER � _ d 9(COMMENCIMGWIiHSECTION7o00jOFDIVISION30FiHEBU51NE55ANDPROFES510N5CO0E,AND Z `X MY LICENSE IS IN FULL FORCE AND EFFECT. �-----� CQ Q LICENSE CLASS���g LIC.NO. j V DATE �"��,'� �\ GONTRACTOR �"(i d Ll:l � WORKERS'COMPENSATION DECLARATION Q � I HEREBVAFFIqM UN�ER PENALN OF PERJUflYONEOFTHE GOLLOWING DECLAFATIONS: z Z _IHAVEANDWILLMAMTAINACEftTIFlCATEOFWNSENTTOSELF-INSUr�EFORWOFlKERS' a ¢ CAMPENSATION,ASPROVIOEDBY5EC710N370oOFTHELABORCODE,FORTHEPERFORMANCE U Q OFTHEWDRKFORWHICHTHISPERMITISISSUE�. � Qw _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONMSURANCE,ASRE�UIREDBYSECTION f , ` 37ooOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISP_RMITIS � ��� � ISSUED.MY Wqcg�Ky�fiS'COMPENS,�710N INSl1R CE CARPoERAN�PO�JCV NLI6ABER ARE CONST{3UCTION j cnaaiEa_ �•.J1�'R.`� ��� - PLAN REVIEW � POLICVNUMBER���' � � �C ELECTRIC �C � (THISSECTIONNEmNOTBEWMPLEfEDOPTHEPERMRISFORONEHItJDPED�011ARS($1W)ORLE55). PLUMBING Z I CERTIFVTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PEFMIT IS ISSUED,I MECHANICAL , � SHALLNOTEMPLOYANYPERSONINANY'MANNERSOASTOBECOMESUBJECTTOTHE [fj WORNEPS'COMPENSHTIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL B INSPECTIONFEE -...��""---"' � SUBJECTTOTHEWORKERS'COMr'ENSATIONPROVISIONSOFSECTION370 ELAB R - ,J .�'�^� �� �� `� � CODE,I SHALL FORTHWITH COMPLY WITH E PROVISIDNS. ISSUANCE .u__�-��—''4r �b� - 3 � �]. � �p�, p i p DATE: -�G3 ,A,P�P�CANT ��5��, __ SMIP § i f Y/ J W� .FA�WORKERS'�TIONCOVERAGEISUNL4WFUL,ANDSHALLBE ENERGYP/C „ - S �� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESLIPTOONEHUNDi1EDTHOUoAND ENERGYPERMIT F DOLLARS(E100,DC0).IN ADDITION TO THE COST OF COMPENSATIDN,DAMAGES AS PROVI�E�FOR IN J SECTION 3�oe OFTHE LABOR CODE,INTEREST.ANDATTOHNEY'S FEES. W . : RETENTION FEE: ��� y � ,� O CONSTRUCTION LENDINGAGENCY �'" ""`�-��."- - -��"��----'�--��_' PRE-ALT FEE: '- � IHEREBYAFFIRMLINDERPENALTYOFPERJURVTHATTHEREISACONSTRUCiIONLENDINGAGENCY FOR7HE PERFORMANCE DFTHE WORK FOR WHICH THIe?ERMIT IS ISSUE�(SEC.308�,CIV.C.;. � , Z LL � LENDEfl'S NAME ' . . F�'�' LENDEfl'SADOFE55 � ICERiIFYTHATIHAVEREA�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECL TOTAL FEES � � � I AGREE TO CAMPLV WITH ALL CITY AN�COUNTY�,ORDINANCES AND STATE L4W5 RELATING TO BUILDING V � d �. CDNSTRUCTION,ANDHEflEBYAUTHOR2EREPRESENTATNE50FTHI5COUNTYiOENiERUPONTHE Z ABOVE�MENTIONE�PROPERTYFORINSPELTION';�uaPoses. COMMENTS - Q �a � � m PEHMITTEEN � � �� �� � SIGNATUREOFPERMI DATE = RECPT.�O. 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