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HomeMy WebLinkAbout14609 (29) ^ � CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMBNT SERVICES , w 21660 E.Copley Drive Suite 19D (909)86€)-3195Fax(909)861-3117 PRES$ '9ti"... BUILDING PE APPLICATION r FIRMI.Y , � , � _ __ _ -- - , : �o AD�DRIESS e, � �__— -�j' DATEICATION � L� ��NUMB R � �/C��— � �'i :� t � � D TE___ ONST. GR OCC .- �APN LOT TRACT OUP p OWNER � 3'� ��'� LL �ADDRE � t"� _..� � "� ZaNING SETBACKS � ` , _ FRONT F1W ❑ ?'O Z ,�ITY � ZIP TELZ73 ZI ' '�v.�7i'� REAR ❑' PPLICANT �.��`4 SIDE/SIQE STREET RW ❑ `� � � �, a 31� � SIDE ❑ , ��.. CON'TRACTQ . „ �O ADDR SS �m�rtr� ZIP� ? L� � � PROPOS D USE � p 2 � o ESIGNERt°�+ � .��� 0.�.5°�`��-?• ��� 1"T"' °f � ADDRESS 6 >I NO.DWEL yr NO. NO. N CITY" ZIP TEL��__QP�'G'm� UNITS 1 � STORIES � BEDROOWIS "' DESCRIPTION FACTOR PSF ADJ.AREANAI:UATION � SQ.;FT. �. OWNEFi-BUILDER DECLARATION SFR1A6�/REM ', r O .. '., ,p , 1 HEpEBY AFFIRM UNDEF�PENALN OF PERIURY THAT I AM EXEMP7 FFOM THE CONTRAGTOflS LF � � GaragelCarporl � � � W �CENSELAWFOA?MEFOLIOWINGPEASON�9EC.7o31.58USINESSAN�PROFES510NSCWE:ANYCI7VOR Z COUNfYWHICHpEWIRESAPEflM�TTOCONSTRUCT,AL7ER,IMPROVE,DEMOLiSH,ORFEPAIRANYSTqUC- �W PdtiOlDBCk - ' � � 'TURE,PCiIOR TO ITS ISSUANCE,ALSO'REQl11RES THeAPPLICAM FOq 5UCH PERMIT TO FILE A SIGNEO � � W � �FESSIONS CODE)OH HPTHEOftIICBJSEo PURSu.WT 70 THE PROVISIONS OF THE CONTRAGTORS LI• . '. . .� .�,CEN5ELAW(CHpP,7ER9(COMMENCINOWI7HSECTIQN700U)CFOIVISIDN30FTHEBU3INESSAN�PRO- u' POOVSPB SHE49EXEMPT7HEREFROMANDTNEBASISFORTHEALLEGEDFXEMP- (� V 'TION.ANYVIOLATIONOFSEC7�ON7031.SBYANYAPPLICAN7FORAPERMITSUBJECTSTHEAPPLICANTTO � R0-R00� °��-'' � � � ':qCMLPBJAI.TYOFNpTMORETH/iH'FNE'HUNdREO�OLUIRS(5590):�: � ' " , � ❑).ASONMEPOFTNEPRORERTY,ORMVEMPLOYEESW17HWAGESASTHpRSOLECAMPENSATION. ❑ COI�1f118fCi81 ' ..ZI �,WIL400THE W06iK.�ANO THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR 9ALE{SEC,7044,eUSI- J . � . '� 'NE89AN�PpOFESSIOWS CODE:THE CONTRAC70R6 LICENSE LAW�OE6 NOT APPLV TO AN OWNER OF ' ' � 'PROPERTVVMO&1LLDSORIMPROV�S�YHFAEON,ANDWHOOOES�SUCHWORKHW,SELFORNERSELFOR �� � � � � ; ��,�: .�.�.. .� ' ' ' � THRIX)GHHISORHEFlOWNEMPY..OVEES,PROVIOEO'TNATSUCFIIMPROVEINBJPSARENOTINTENOFAOR 'm ' •' - ' ' '' � ' WQ �FFEREOFOPSAL6IF,HOWEVER,7HEBUILDINGORIMPROVEMENTISSOL�WITFIINONEYEAROFCOMPLE- -' � � .❑I.ASoWNEROFTHEPRO�ER'fY AM EXCLUSN 6F PpOVINO THA7 HE OR SHE UID NOT 9UIID OR � �IMPROVE FOF THE PURPOSE OF SALE � �,` � TKKI.TryEOWNER•BUILDERWILL�WAYETHEBURDEIVELYCOMRACTINGWIiHLICENSEOWNTRAG7oRS ,. �70 GONSTfiUCT THE VRQIECi 5EC.7oee,BUSIN6SS MID PROFESSIONS CADE:THE CONTFACTORS LI-� V31U3[lOf1 . �� � /�DJ.AREA �'� ,��,��. �:CEN5EI�IWDO�NOTAPPLY70pNOWNEROFAPROPERTYWHOBl11LD50RIMPROVESTHEREON,AND . . '� ���� ',�YIFIOCONTRACT9FOR3UCI4'PROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECANTM0. QUANFITY DESCRIPTION - ' FEE" � . �. .,NRSLICENSELAW.). ., .. . . , ... . . . . ., �Q ❑I AkY EXEMPTUNDEH SEC.� B.&P.G FOflTHIS'REASON � ,��.. �� � � . , .,. , .. ,�.. ' �'L' bATE � OWNER �� � ' � � �� ' '. ..� ., . .. . .W. . . . , � �q[�. - LICENSEDCONTFIACTORS DECLARATION � `W _ � IS. IHERff1VAFFIflMUNOERPENALNOFPERJURYTHATIAMLICENSED�NOEflPROVI5pN50FCHAPiEP �v . � �� ' � �e�(COMMENCINO WITH SECTION 70W)OF DlVISION 3 OFTHE BUSINESS PNO PROFESSIONS CODE,AND � ' .'� MY LICBiSE IS IN NI,L FOR�FJJD EFFECT. ^ � � � � ���� LICENSE CL455 � LIC.NO ' ���°�� �� . . ~�� .DATE 9.� �: .. .� COPtfRACTOR � �'� t p J U. ttl ' � WORKERS'COMPENSATIO'�DECLARATION ��'2,� Q � IHEREBYAFFIHMUNDERPENaLLTYPFP�RIURVONEOFTHEFOLLOWMGDECLARA7'IONS: U � � � � 41] Q . �; ,_INAVEAN�WILIMAiNTAINACERi1FICATEOFCONSENTTOSEIF-INSUREFOqWOflKERS' 2 '� � � COMPEN5AT101V,AS PROVIDEb @V SECTION 31o00F THELABOR CODE,FOR THE PERFORMANCE �U � OF THE WORK FOR WHICH THIS�PERMIT IS f55UE�. � - . W _IHAVEAN�WILLMAINTAINWORKERS'WM1iPEN3ATIONIN9URANCE.A9REQUIREDBYSECTION ���� /'y 0 37000FTME LABOR CODE,FORTHE PERFORMANCE OF THE WORK FOR WHICH TNIS PERMIT IS id' IS9UED.MY WORKEA3'CQMPErySATION IN RANCE CARRIEW AN�POLICY NUM6ERARE: CONSTRUCTION a _ � CARRIER� "� AA - f PLqN REVIEW Q , POLICVNUM9ER '� � ' F ELECTRIC wc ¢ (fH16SECfFJNNEHJNOTBEWMq.,ETEDOFTHEPEWARISFORO�dEHUf�RE4�1.1AR5�$700)ORLESS} PLUMBING G � W�� MECHANICAL Z � I CEPTIFY7HAT IN 11VE PERFORMANCE OF THE WORK FOR WHICH THiS PERMIi IS ISSIJEO,I C,j' SHALLNOTEMPLDYANYP�fl50NINANYAIANNER50A5T09ECOMESUBJECTTOTFIE ?NSPECTIONFEE � WOPoCERS'COMPENSATION,LAWS OF CALIFORNIA,ANDAOREE TfiAT IF 19i0UL�BECAME � ' � 5U&IECTTOTHEWORKERS'C0�7PENSATION'PROVISIONSOFSECTION37COOF?HEUBOR ' aCOD8E,I SHAtLL�FORTHWITH COMPLY WI7H THOSE PFqVISIONS. I SSUANCE ' � � � DA7E:-��*�0 `6 . SMIP a APPLICANT. � WAPNING:FAIUIHETO SECllHE WORKEps'COMPEN5ATION COVERAGE IS UNL4WFUL,AND SHALL BE �NERC�Y P/C � ?���, `y" �� SU&IECTAN EMPLOYER TO CRIMMAL PENALTIESAND qVIL FINES UP 700NE HUNDWED THOU3AND �NERGY PEFMIT ' DOLLARS(Si00,a00),INAODITIONTOhiECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN � � ' S€CTION97CeOFTHELkBORCODE,INTEREST,AN�ATTORNEY'SFEES. ' fi'�TENTIONFEE: ��� � � CONSTRUCSION LENDING AGENCY PRE•ALT FEE: � TASC�`r,y.ry�.� � �� 1HEREdVAFFIpAIUNDEHPENALTVOFPERJUHYTHATTHEFEISACONSTRUCTIONLENDINGAGENCY FORTHE VERFOflMANCE OFTHE WOWK FOR WhlIGH TF715 PEflM1715155UED(SEC.aas],CIV.C.). � , _ . Z. W. �' LENOER'S NAME - ' ' 1� LENDER'6ADDRESS � 2. . f w IAOREETOHCAMPLVWTHAL CIffYAN COUNNORDTMANC SANOSTATOEtAWSRELATNGIT09UIR01NG Ty(/�'�+TAL/�/Fey� S �'��"��/f/�/e/�j . . ��� �� CONSTRt1CTION.ANDHeREBYAUIHORIZEREPRESENTATIVE50FTHI5CWNTYTOENTEflUPONTHE �( �� 9� E"j_m / I : ' Z .ABOVEMENTqNE�PROPEHTYFORiNSPECTIONPURPO5E5. 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