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HomeMy WebLinkAbout16342 � "! Z'�'� CITY OF DIAMOND BAR �j r , ^ f� - DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES � � � n 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 P E$$ ����Y�� BUII,DING PERMIT APPLTCATION FIR1NI..Y ���eI�J �I�=GC..6-C11J I��Gt� � DATE , .. .. . �. . . ., � JOBSITE APPLICATION '�y �i PERMIT �I /C o ADDR�SS '-d NUMBER �'� � � APN LOT R CT DA EE � � B pNST. GROUP p OWNER ZONING SETBACKS o ADDRESS��" �, � Z CITY � ZIP �TEL. " REART RW ❑ g APPUCANT TEL. SIDFJSIDE STREET RW ❑ � CONTRACTOR f.� f SIDE O � ADDRESS � PROPOSED USE o CITY �-�= ZIP �`fEL. wo ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. cr� DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA710N SFR�ADDIREM p !HEREBY AFFlRM UNDER PENALTY OF PEAJURY THAT 1 AM E%EMPT FROM THE CONTRACTORS LI- GaI896/C8(POR W CEHSEUWFCXiTHEFOLLOWINGHEASON(SEC.7o37.58U5BJE55ANDPROFESSIONSCODE:ANYCiTVOR (/? C7 COUNTI'WFIICHREq11RE3APERMR7000N3TRUCT,AITER,IMPROVE,DEMOL�SH,ORREPARAN45TRUC- IW Pe�iO/DBCk �Z TURE,PRI6R 70 ITS ISSUANCE,ALSO REW IHES TNE APPLICANT FOR SUCH PERMIT TO FILE A S�GNED STATEMENT THAT HE OR 6HE IS IICENSED PURSUANT TO THE PROVISIONS OF THE CON7RACTORS L'- � CENSE LAW(CHAPTER Y(COMMENGINO WITH SECTION 7000)OF�IVISION 30F THE 6USINE55 pND PP.O- � P�oVSpa FESSIONS CODE)OR THAT HE OR SHE IS E%EAIP7 THEREFqOM AND THE BASIS FORTNE ALLEGED E%EMP- TION.ANYVIOUTqNOFSECTION7031.5BYANVAPPUCANTFORAPERMITSUBJECTSTHEAPPUCMITTO 7� Re-ROOf F, ACIVIL PEN�L7Y OF NOT MORE THINI FIVE HUNDHED DOLLARS�S5oo).): � OI,ASOVMEROFiHEPROPERT',OREIYEMPLOYEESWITNWAGESASTHEIRSOLECOMPENSATION, � CommBrda� - YALL DO THE WORK,AND THE STRUCTURE 13 NOT INTENDE�OR OFFERED FOq SALE(SEC.7041,BU51� J � NESS ANO PROFESSIONS CODE:THE CANTqACTORS IICENSE LAW OOES NOT APPLY TO AN OWNER OF = PROPERTV MMO BUILDS OR IMPROVESTHEREON,AND Nhi000ES SUCH WCNiK HIIASELf OR HERSELF OR � THRIXI(3HH�SORFIEROWNEMPLOYEE5,7ROYI�ED7HATSUCHIMPROVEMENTSARENOTINTENDE00R m � OiFEREOWRSALEIf,FIDWEVE0.'�1�EBUILDINOORIMPROVEMENTISSOL�WITPoNONEYEPAOFCDMPLE- z TqN,THE ONMER-BUfLDER WILL HAVE 7HE BUPDEN OP PNOVIN6 THAT HE OR SHE DID NO7 BUILD OR = IMPROVEWRTHEPUfiPOSEOFSALE} W ❑I,AS OWNEH OFTHE PROPEHTY,NA EXCLl1SIVEI V f�NTPACTNG WITH LICEN5ED CONTRACTORffi � TO CONSTRUCT 7HE PRQlECT(SEC.70N,OUSINESS MI�PROfESSIDNS CODE:THE CONTRACTORS LI- VelUltitln ADJ.AREA W CENSEUW WESNOTAPPLYTOANOWNEflOF�pROPERTYWNOBUIL�50RIMPiiOVE57HEREbN,AND � WHOCOMRACTSFOPSUCNPR0.IECTSWITHACONTRACTOR(S)LICENSEOPURSUANTTOTHECONTRAG QUANT�TY DESCRIPTION FEE Y 'fORS UCENSE LAW.). Q ❑I AM E%EMPT 11NOEH SEC. ,_ `B.L P.C.FOR THIS REASON U 3 � LL' DA7E_ OWNER`__ F Z W � LfCENSED CONTRACTORS DECLARATION W I HEREBYAFfIRN UNpER PENAIT'OF PEiUURV TH0.T IAM LICENSED UNDER PROVISIDNS OF CHAPTER �r � Y(COMMENqNO WITN SECTKKJ 7000�Of D�VISION 3 OF THE BUS�NESSANO PROFESSIOWS t�DE,ANO Z � ' X MYLICENSE IS IN FULI FORCEAh�EFFECT. � m lLJ +� /') g 0 LICENSE C SS ` � LIC.NO_�4� J V DATE � �� _ GON7RACTOR W � WORKERS'COMPENSATION DECI_ARATION Q � �HEqE6VAFFIRMUNDERPENALTVOFPERJUPVONEOFTHEFOILOWINGDECLARATIONS: � � Z Q O I HAVE AND WIIL A9AINTAIN ACERTIFICA7E OK CONSENTTO SELF-INSURE FOR NbFKEFS' S I � �SATION,AS PROYIOFD BY SECTION 3�0o OF THE LA8[Xi CODE,FOP TNE PE%KOftMANCE w E N`ORK FOR WHICH THIS PERMIT IS ISSUE�. � � W _I HAVE AND NALL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BV SECTION Q ^ 370aOFTHE4AF?OflCDOf,NRTHFPERFORMANCEOFTNEWORKFORWHICHTHISPERMIT�$ ISSUED.MY W06tKER5' MPEN ATION I NC CqRPI R�_D POLICY Nt1MBERARE'. CONSTRUCTION .. � cnRRiER � ' �` PLAY REVIEW � Po��cV NUMBER _ .�.�. — ELECTRIC � (iHSSELT�ONNe8�No7'BEmMPtE7EDOFTHEPEPI�YTISP�RCNlEHuhDREoOOUAFlS(ftaa)Oat.F.SS). PLUMBING 0 Z 1 CERTIFV THAT IN THE Pr'AFORMANCE OF THE VVORK fOR WNICN THIS PEPAAIT IS ISSUEO,I MECHANICAL __ � SHOY.LNOTEMPLOYANVPERSONINANYMFlNNERSOA5T08ECAMESUBJECTTOTh1E � WORKERS'CAA9 NSATION LAWS OF flNIA.AND AGREE THAT IF I SHOULU BECOM INSPEGTION FEE = SU CTT07h' WPHKERS'�'AMPEN ATIO ISIONSOFSECTION37000FT R 4 CA I SHAIL OWTHWI?H L'OMPL" TH SE P VI510 ISSUANCE � 1� APPLICANT: SMIP p DATE� "J WARNING FAILURc O SECURE WOftNERS'COMFENSRTION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C J Sl/&IECTAN EMPtAYER TO CRIMINAL PENALTIES AN�CIVIL FINES UP TO ONE HUNDREO THOUSANp � DOII.AFS�5100,0U0),INADDITIONTOTHECOSTOFCAMPENSATION,OAMAGESASPROVID'cOFOR'�N ENERGYPERMIT J SECTION 3708 Of 1HE LABOR CDOE,VNiEREST,ANO ATTORNEY'S FEES. RETENTION FEE: � d CpNSTRUCTION LENDING AGENCY PREALT FEE: � I HEPE9Y AFFIRM UNDER PENAL'V OF PEPJURV THATTHERE IS A CONSTRUCTION LENDING AGENCV FOR THE PERFOREtANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED�SEC.309'1.CIV C.�, Z W � LENDER'SNAME - _ P— LENDER'SADDRE55 � I CERTIFYTHAT 1 HAVE READ THIS APPLICATION ANO STATE THATTHE A80VE INFORMATION IS CARRECT. TOTAL FE ES � I AGRE£TO COhIPLV WITIa ALL CI?Y AND COUNTY OR�INANCE ANO STATE LAWS REUTING TO BUILDING CONSTRUCTKKJ,AN�HEREBY AUTHORRE fiEPi7ESCNTATNE OF THIS COUNNTO EMER UPON THE Zp90VE-MEfiTIONED PROPERTY FOR INSPECIiorv vuRPoses. COMMENTS � �, � � m PERMITT E(Pfi14T) . d � �•— � SIGNATURE PERMITT � A = RECPT.NO. PAIO BY VALIDATiON ~ WHITE—Ospartment Copy,YELLOW--finance Copy,PINK—Assessor Copy.GOLDENR06—File Copy,GREEN—ApplicanYs Gopy -� . ., ,.�.:'r,;.. 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