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HomeMy WebLinkAbout17267 (26) �� _ CITY OF DIAMOND BAR �, � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ^w�� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS `�-H��� BUILDIPIG PERMIT APPLICATION FIRMLY y JOBSITE APPLICATI N PERMIT ,r� 7 p/p o ADDRESS �Q— DATE C�I I C3 C NUMBER �.y(�' I # °r APN OT __ T ACT D TEE O ST. GROUP p OWNER ! _----- o ADDRESS ZONING SETBACKS z CI ZIR�� 7EL. d � FRONT RW ❑ � APPL CANT TEL. REAR � z — SIDE/SIDE STREET RW ❑ Q CONTRACT SIDE ❑ ADDRESS -�r � � � CI ZIP TEL �'"OD .*j� U � ARCH/ENG! r�� z DESIGNER w N .DW . NO. NO. � ADDRESS UNITS STDRIES BEDROOMS = CITY ZIP TEL. cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEF DECLARATION $FR/ADD/REM O p I HEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM TNE CONTRACTORS LI� Gdffl9B/CBfPOfI W CENSELAWFORTHEFOLLOWINGPEASON(SEC.7031.56USINESSANDPROFESSIOVSCODE:ANVCITYOR (� U COUNNWHICHRE�UIRESAPERMITTOCANSTFUCT,ALTER,IMPRCVE.DEMOLISH,ORREPAIRANYSTRUC� w TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES 7HE APPLICqNT FOR SIiCH PERMIT TO FILE A SIGNEO w PflfiO/DBCk � STATEMENT THAT HE Ofl SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � � CENSE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF UIVISION 3 OF THE BUSINE55 AND PRO� POOI/SPB 0 FESSIONSGO�E)ORiHATHEOFSHEISE%EMPTTHEREFFOMAN�THEBASISFORTHEALLEGEDEXEMP- (� U 710N.ANYVIOLATIONOFSEC710N7031.58YANYAPPLICAN7FORAPERMITS'JBJECTSTHEAPPUCANTTO Z Re-ROOf ACIVIL PENALTY Of NOT MORE TiAN fIVE HUN�REO OOLLAFS(SSoo).): � ❑I.ASOWNEROFTHEPROPERTY.ORMVEMPLOYEF_SWITHWAGESASTHEIReO�ECOMPENSATION, 0 COfnfilBfCldl Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.704a,BU51- �J - � NESSANU PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY 70 AN OWNER OF = PROPERTY WHO BUILDS OR IMPROVES THEREON,AN�WHO�OES SUCH WORK HIMSELF OP HERSELF OR w7HROUGHHISORHEROWNEMPLOYEES,PFi0VI0EDTHATSUGHIMPROVEMENTSARENOTINTENDEDOF m 0 OFFEREOFORSALE.IF,HOWEVER,THEBUIIDINGORIMPROVEMENTIS50LDWITHINONEYEAqOFCOMPLE- Z TION,THE OWNER�BUILDER WILL HAVE'HE BURDEN OF PPOVING TIiAT HE OR SNE DID NOT BUILD OR = IMPFOVEFOHTHEPURPOSEOFSALE), W ❑I,AS OWNER OF THE PROPERTV,AM EXCLUSIVELY CONTRAC7ING WITH LICENSEO CONTRACTORS � TO CANSTHUCT THE PROJECT(SEC.7094,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- V0IU0I10� ADJ.AREA W CENSELAW�OESNOTAPPLYTOANONMEROFAPRO?FRTVWHOBIIILOSORIMPROVESTHEpEON,AN� � WHOCONTRACTSFORSUCHPPOJECTSWITHACONTRACTOR(S)LICENSEOPURSUANTTOTHECONTRAC- QUANTITY DESGRIPTION FEE Y TOqSUCENSELAW.). � ❑I AM E%EMPT UN�ER SEC. ___B,&P.C.FOR THIS REASON Q ?�, U � � DATE OWNER F- � � � LICENSED CONTRACTORS DECLARATION W 4 � I HEREBVAFFIRM UNDER PENALTYOF PEFJURY THAT IAI�A LICENSED UNDER PROVISIONS OF CHAPTER � � e(COMMENCMGWITHSECTIONlOoo�OFDIVISION3OFTHEBUSINE55ANDPROFESSIONSCAOE,AND Z 1X MV UCENSE IS IN FULI FORCE AND EFFECT. m � �ICENSE CLASS LIC.NO.1Z�� � U �ATE � I" CONTPACTO � d W � WORKERS'COMPENSATION DECLARATION ¢ � I HEREBYAFFIqM UNDEii PENALTV OF PEFJURY ONE OFTHE FOLLOWING DECLAFATIONS; Z � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEFS' _ ¢ CAMVENSATION,ASPROVIDEDBYSECTION3��oOFTHELABORCODE,FORTHEPERFORMANCE U Q OFTHE WORK FOR WHICH THIS PEPMIT IS ISSUED. � w _I HAVE AN�WILL MAIN7AIN WORNERS'COMPENSATION INSURANCE,AS fiEOUIRED BY SECTION O 370o OP 7HE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS f�/� ISSUEO.MY WORKERS'C PENSATION INSURANCE CARRIER. D POLICV NUMBER ARE: CONSTRUCTION LQ� � CARRIER ���p PLAN REVIEW Z POLICV NUMBER _ ���_2i�=��/ ELECTRIC Q ...... � (1HISSEGT10NNcmNO78EOJMl'LEfEDOF1HEPERMITISFORONEHUnDREDDOLLAFiS(y100)ORLESS). PLUMBING M�`� � nM1��-"'""i"��?'��''"�''�'M���. W 1....._ ..... _:�....�... � � r H„� Z 1 CERTIFY THAT IN THE PERF�RMANCE OF THE WORK FOR WHICH THIS PEpM1T IS ISSUED,I MECHANICAL "" CJ SHALL NOT EMPLOV ANV FERSON IN ANY MA�NER 50 AS TO BECOME Sl18JECT TOTHE T�"`� � WORKERS'COMPENSATION LAWS OF CALIFORVIA,AND AGREETHAT IF I SHOULO BECOME INSPECTION FEE �' � ? SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37ao OF 7HE UBOfl � n n-�GG� � 4��� �� CO�E,I SHALL FORTHWITH COMPLV W'.TH TMOSE PROVISIONS. ISSUANCE � SMIP •7� p �ATE: APPLICANE _ J WARNING:FAILURETO SECURE WORKERS'COMOENSATION COVERAG'c IS UNLAWFUL,AND SHALL BE ENERGY P/C E �+-.._._. ,J ... .,c:_.�........,..._,...._.__.re-....... ...........� � SUBJECTAN EMPLOYERTO CRIMINAL PENAUIES AND CIVIL FINES UP TOONE HUNDREDTHOUSAND ENERGY PERMIT DOLLARS(5100,0001.IN ADDITION TO 7HG COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 3]OB OF THE LABOR CODE,MTEREST,AND ATTOPNEY'S FEES. RETENTION FEE: I. � d CONSTRUCTION LENOING AGENCY PRE-ALT FEE: O � I HEREBV AFFIqM UNDER PEN�LTV OF PERJURV THATTHERE IS ACCNSTRVCTION IENDING AGENCV FOR THE PERFORNANCEOFTHE WORK FOR WHIC4 TH�S PEflMIT IS'.SSUE��SEC.3a97,CIV.G�. Z w � LENDER'SNAME F— LENDEfl'SADDflE55 � ICERTIFVTHATIHAVEREADTHISAPPUCATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT. TOTALFEES �� W I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUIL�INC � /� �� d � CONSTRUCTION,ANDHEAEBVAUTHORI2EREPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE z A�OVE�MENTIONED VROPERTY FOR INSPECTION PURPOSES. o ��� COMMENTS J � _____..... ._____ _ _— � PERMITTEE AME(Pftl T��� � Q ! Uj SIGNATUREOFPERM EE DA E = RECPT.NO. � PAID BVG� VALIDATION ~ WHITE—De artmentCo YELLOW—FinanceCo PINK—AssessorCo GOLDENROD--FileCo GREEN—A IicanYsCo P PY. PY. PY. PY, PP PY �. ,,, ,� , . „ -.. . ,, , ,.,. , , y �� �.,W.� ��, ������ 'a�� �h�� �r���`��' ``.�� �"��� � � _ �``„� ��:n..�e� ��� � -� .,� �� � ��� �_°� �� � a � �� ��� ��� �� d � �� . � ': ������� _� x e �.� °� � *� �dz���'�, � �R� ����5 "��.��a �'�� � ��� a �� � , ��,� � � � .., _a^. - � -� �., m�` �' � �. ", a����,��.!m "� : ay'`3 o-.:� � C a��arm :'�: ��...� � .�, ..� :�'� ���::«: �: � U ,r ' � . �r7�, � �� �. 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