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HomeMy WebLinkAbout15538 (9) � � � T �- _ _��,� CITY OF DIAMOND BAR � � DEPARTMENT OF COMMUNITY&DEYELOFMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 c� PRE$$, ,,.. , BUII.DING�"ERIVIIT APPLICATIQN _� � C „ A�, FIRMLY , _ ', � JOBSITE ��� � „�i�� Y APPLICATIO -�. PERMIT '��',�LYP/C !� o ADDRESS d�r DATE �`�% NUMBER��''J✓(I # � APN LOT TRACT ISSUE � /}yr) TYPE OCC DATE " 8�1 CONST. GROUP p OWNER" ` � -',Cy ' � - .� ,P� o ADDRESS � � f� _ ZONING SETBACKS gCINlJ � ZIPGJ'_l_2� TEI( � FRONT RW ❑ APPLICANT ��� I TEL. REAR ❑�,„_ Z StDE/SIQE STREET RW O � CONiRACTOR 1 ❑ SIDE o C TM ESS�� �,� ZIP �+� TEC,� ..-- PRdPOSED USE �� o ARCHlENG�� z DESlGNER 'a ADDRESS •-" � � y. NO.oWEL. NO. NO. �� QITY ZIP TE������z/ //�f UNITS �_ STORIES � BEDROOMS 'v� � �� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O OWNER-BUILDER DECLARATION SFR/ADD/REM � gr � ' �p� �� I HEREBY AFFIRM UNDEfl PENALTY OF PERJURY THAT I AM EXEMPT FROM THE fANTRACTORS LI- (�'af898/C8f{70f[ � � � � �, W 'CENSELAWFOfl7HEFOLLOWING.REA50N(SEC.)o31.5BU51NE55ANDPROFE5S10N5CODE:ANYCITYOR �.(n �7u� .COUNiYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPqOYE,�EMOLISH,ORREPAIRANYSTflUG W PyS10/DeGk II I,� TUHE,PRIOR TO ITS ISSUMiCE.ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED , w � � s. '.�STATEMENT THAT HE OR SHE IS LICENSEO�Pl1R5UAN7 70 THE PROVISIONS DF THE CONTRACTORS LI. � ., � '.CENSEUW(CHAPTEF.IB(COMM�ICINGWITHSECTION�ooOJOFDIVISION3OFTHEBUSINESSPN�PRO- POOVSPB � ��FESSIONSCODE)ORTHATHEOR�'SHEISEXEMP7THEREFROMANDTHE6ASISFORTHEAILEGE�EXEMP� ��(� �� ,TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTPORAPERMITSU&lEGTSTHEAPPLICAN(70 �;Z Re-Roof �, '�� �,A qVil PENALTY OF NOT MORE 7HAN FNE HUN6RED DOLLAflS�5500).): i il� .. ❑I,ASOWNEROF7HEPROP,ERTY,OfiMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, � COmmeroial . - � �' �..WILL DO THE WORK,MJD iHE STRUCTURE IS N0T INTENDED OR OFFEREO FOR SALE ISEC.7044,BU51� J ' �'.NE55 AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEF OF � �' '9 '�i�. '�.p1iOpERiYNM1lO8URD50RIMPROVESTHEREON,ANUWHO00E5SUCHWORKHIMSELFORHERSELFOfl �� � � y�7�� � �'�� '�THqWGHHISORHEROWNEMPLOVEES,PROVIDE�THATSUCHIMPROYEMENTSARENOTINTEN�EDOR m / . li�,p'.. 'IOFFEREDPoASALEIF,HOWEVERjhIEBUILDINGORIMPROVEM1IBJTISSOLDWITHINONEYEAqOFfAMPLE I I ,Z ,,TION.THE OWNEH-BUIL�EH WIL�HP.Yc hiE BURDEN OF PROVING iHAT HE OR SHE DI�NOT BU�ID OA . _. IMPROVEFOR7FIE?URPOSEOFSQE). - � ❑I,AS OWNER OF THE PROPERTV,AP7 ERCU151VELYCONTRACTING WITH LICENSE�CONTRACTORS �� I�� ",TO CONSTRUCT THE PROJECT(SEC.7064';Bl1SI1�ESS ANO PROFESSIONS CODE:THE CONTRACTORS LI- VflIUfl110� � � ADJ.AREA � � . �W� ''CENSELAWDOESNOTAPPLYT6pNOWNEROFAPROPERTYbVHOBUILDSORIMPpOVESTHEREON,AND '��'�. �NM1iOCOMTRACTSFORSUCHPRQIECTSWITHA�N7RACTOR(S)UCENSEQPUR6UAN7TOTHECONTRAC QUANTIN DESCRIPTIOR� FEE � .� '�'TORS LICENSE LAW.j. '�o �❑I AM EXEMPT UNDER SEC. S.8 P.C.FOR THIS REASON Q � i U ,Z�, OATE OWNEfi U � r�,. W Q LICENSED CONTRACTORS DECLARATION W . �, OC'�, .IHERE9YAFFIRMUNDERPENAISYOFPESiJURY3HATi`t�MLICENSEDUNDERPROVI510N50FCHAPTEfl '� ,.,a„�y��6 �'�, �9(CbMMENCINOWITHSECTI0N70a0)OF�NISION30FYHEBUSINESSANDPROFESSION9cADE,AND Z - . `�� � . � � �CLI� MYUCENSE IS IN FULL FQACE AND EFFECT. � m e ,, � LLI /-� �� � � � � � � 4�y;�4's� . o.l, LICENSE CLASS_ I� � IIC.N0. �,J ., � J. y�.�fa�., . ��� ;y,,. ~' DATE� �"g��. �+s?t'S ,-CONTRACTOR�� a ,:;g. �. �A �. ' -' W'' -�'-,' - . - .. - :� 1' , . �.q��S`� Y� i. '+ . . . . � x Y9.. �' WOFiKERS'CDMPENSATION DEC RAl10N -� q �'� II=�,, ... � . ¢ . �i�"'e�"e_,7 , . , �I��. ,IHEREBYAFFIRMUNDERPEPJALTYOFPERJURYONEOFTHEWLLO INGDECLARATIONS: . Z , ,' ',���','�� _I HAV'c AND WILL MAINTAIN A CERTiFICATE OF CONSENT TO SELF-iNSURE FOR VJORKERS' _ � COIARBJSATION,ASPROVIDEDBVSECTION370UOFTHeIABORCO�E,FORTHEPERFORMANCE U , � OFTHE WORK FOR WHICH THI3 PEHMIT IS 133UED. �,, . � ', QW _i HAVE AND WILL MAINTAIN WORKER5 COM?ENSATI6N INSIJRANCE;AS pE�ulqEq 6Y SEC710N � 2 .�r�/ �/ / /J � ��' 37000FTHELABORCODE,FORTHEpERWRMANCEOFTHEWORKWRWHIC4THISPERM1T15 ��� -7�� 1 � i-��(_�(/J ISSUEC.MY WORKER9'(?7MPENSATKKJ IN3URANCE CARRIEfl AND POLICY NUMBERARE: CONSTRUCTION �-� � 1 KJ [ 'Q °�� ��/.J'� ,�71�� .>� cARRiER_ � PLANREVIEW �[JL/ � 4��'� aoucvNun�eea � F� ��� --�� ELECTRIC f�} � � � O,' (MI65ECfqNNE�NOTBECOMf4Ef'rDOFTiiEPERNtlTSFORIXJEHUM1bREDD01JAR5(5100)ORLESSZ PLUMBING --_��+ • '�, �Z�, 1 CEflTIFY THA71N THE PERFOFUAANCE OF THE WORK FOR WHICHTHIS PERMIT IS�SSUED,I MECHANICAL SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJEC7 TO THE �„'� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGqEETHATIFISHOULOBECOME INSPECTIONFEE � j SU&IECTTO THE WORNERS'COMPENSATION PpOVISIONS OF S'eCTION 3 �OF THE IABOR /�� ' cooe, sHw.Fonr wirHcoMp�vwin-imo � visioN ISSUANCE , vv O �' , �,�� DATE: � ' APPLICANP, �SM{P �':';;, WARNINGFAILURETOSECUREWORKERS'COMPENS�, IONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C � ' '�, ��,',�� SU&IECTANEMPLOYERTOCRIMINALPENA�TIESAN� IVILFINESUPTOONEHUNDREOTHOUSAND ENERGYPERMIT DOLUflS(5700,000),W AOOITION TOTHE COST OF CO IPENSATION,DAMAGES AS PROVIDE�PoR IN �'�J�:��', SECTION3708OFTHELABORCODE,INTEREST,ANDATTORNEI"SFEES. � '! �,ppy RETENTIONFEE: y`�i � �� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O, �'� I HEflEBYAFFiRM UNDER PENALTY DF PERJURY THATTHERE IS ACONSTRUCTION IENDING AGENCY - � " , FORTHEPEflFOHMANCEOFTHEWOflKFOftWHICHTHISPERMITI5155UED(SEC.3�W,CIY.C.). . ,;Z� . . . . , W '�.,� LEN�ER'S NPME . � F_, LENOER'SAODRESS - - W�. ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEA60VEINf-0RMATIONISCARRECT. TOTAL FEES � � , �D � . ///��� - �'� I AGREE TO CAMPLY WI7H ALL CIiYAND COUNTY DR�INANCESAND STATE LAWS RELATiNG TO BUILDING ����L': . �>, CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF7HIS COUNTV TO ENTER IJPoN THE � - Z,', ABOVE�MENTIONED PROPEHTV FO INSPECTION PURPOSE9� , . 0,� / COMMENT . J. f�� , m�.. 2 �� ' . � Q, PERMITTEF NAM - . � � �� � '� ���'�. SIGNATURE ITT DATE � . ! „_�, RECPT.NO. PAID BY 'VALIDATION � � ~ WHITE—Dapartment Co VELLOW—Financa Co PINK—Assessa Co G LDENRO ile Co GREEN— IicanCs Co � PY. PY. PY. 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