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HomeMy WebLinkAbout16299 (23) ____..._. ., . . .._. ._ . ������ �� CITY OF DIAMOND BAR G�'.��—�� DEPARTMENT OF COMMUNITY&DEVELOPIVIENT SBRVICES T �; 21660 E.Copley Drive Suite 190 �����_ ��� (909)860-3195 Fax(909)861-3117 E$s �° BUILDIIVG P�RMIT APPLICATION�' ' - FIR ��LY _ _ .. ,. ,._ , . . _ o D RIESS SUJ �+���n� ��. APPLICATION �j �- � NUMBER #� DATE �t" $ ISSUE N.{ TYPE OCC APN----�� LOT TRACT DATE V � CONST. GROUP p OWNER •Lft/l/ff / 11t$ C�� "" AODRESS , D ZONING SETBAGKS 2 CITY -1�/'��a'/F IP TEL .�/� GI� FRONT RW ❑ �j APPLICANT TEL REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRAC70R L� ��. SIDE ❑ � ADDRESS � PflOPOSED USE �''xT�� / E� CfTY . � ZI' b 7EL T � ARCWENG/ DESIGNER NO.DWEL. NO. NO. AODRESS UNITS STORIES BEDROOMS a CITY ZIP 7EL. � DESCRIPTION SQ.F'f. FACTOR PSF ADJ.AREANALUATION � pOWNER-BUIL�ER DECLARATIpN SFR/ADD/REM Q I FIENEBY APFlHM UNDER PENPLTY OF PERIURY THAT I AM E%EMPT FFOM THE CONTRACTORS LI- G8f8(JB/Cff�OR � CENSELAWFOpTHEFOLLOWMIGREASON(SEC.7037.5BUSINESSANDPROFESSIONSCDDE:kNVCITYOF (� COUNTYWHICHf��UIRESA�ERMITTOCONSIAUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W P0ti0/DeCk 'NRE,PRIOR TO ITS ISSVANCE,kL30 REQUIqES THE APPLICANT FOR SUCH PERMI7 TO FII.&A SIGNED w STATEMENT THAT HE OR SNE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI• � CENSEUW�CI-IAPTER9(COMMENCMOWI7HSECTION700o)OFDIVISIONaOF7HE611SINE55ANDPRO- � Po0U5pa fESSIONSCOD�ORTHATHEOR5ME15E%EMPTTHEREFROMANDTHEBASISfORTHEALLEGEDE%EMP• (� TIOOI.ANVYIOLATIONOFSECTIpN7o31.5BYANVAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTTO T` R8-RDOf �, A CML PENALTY OF NOT MORE 1'HAN fiVE HUNDRED DOLURS�5500).�: � ❑I,A90WNEROFTHEPROPERTV,ORMVEMPIAYEESWITHWAGESASTHEIRSOLECOMPENbATION, Q CORifIIBfCId� - VALL DO THE WORK,ANO THE STRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.70M.9U56 J NE55 AND PqOFES510NS CODE:TME CONTRACTORS UCENSE UW OOES NOTAPPLY�"O AN OWNER OF � PIiOPERTYWVIOBULDSORIMPHOVFSTNEqEON.0.NDWHODOESSUCHWORKHIMSELFORHERSELFOR m � THHOU(3H HIS OR HER ONM EMPLOYEES,PROV�DEO7HAT 3UCH IMPROVEMENTS ARE NOT INTENDED OR � OFfEREDFORSAI.EIf,F10N/EVER�8�1��D�NGORIMPPOVE4IENTISSOLbWtTHINONEYEAROFCAMPLE- � TION,7HE OWNER�9UILDER WILL HAVE THE BUflDEN OF PROY�NO THAT HE Ofi SHE DID NO7 BUILD OR � IMPf�VEFORTHEPURPOSEOFSALE�. O I.AS DNMER OF THE PROPEfl7Y,AM EXCW SIYELY CONTRACTING WITN UCENSED CONTRAC70RS � TO OON6THUCT THE PRQlECT(SEC,7a.11,BUSINESS AND PROFESSIONS COCE:THE CONTRACTORS LI- VAluallOfl ADJ.AREA L�J CENSE44WDOESNOiAPPLY70ANOWhEROFAPROPERTYWHOOUIlA50RIMPROVE9THEflEON,AND J- WFiOCONTRqCT6FORSUCHPROJECTSWITHACOMRACTOF(S}UCENSEOPL'RSUANTTOTHELbNiRAP QUANTITY DESCRIPTION FEE �� TORS�ICENSE LAW.). �A3 ❑I AM E%EMPT UNDER SEC.__,_ B.fi P.C.FOR THIS REASON Q y � � DA7E .,�_ OWNER__.__. U � W S UCENSED CONTRACTORS DECLAFATION � � W iHEREBYAFFIRMUNDERPENALTVOFPERIURYTFIATIAMLICENSE�UNDERPROVISIONSOFCH0.P7Efl � ��,:�E� �ef..T p R� 9(COMMENdNCi Wlhl SECTION 7000)Oi OIVISION 3 OF THE BUSME55 ANO PROfESSIONS CODE,ANO Z Y. MY LICENSE IS IN FULL F�RCEPND EfFEC7: m 0 UCENSE CIASS�--3� LIC,NO.�.._(L_!_� /���� � � V DATE_���_ CONTRACTOR�/'_ a L1J � WORK'ERS'COMPEN5A710N DECLARATION Q � I HEREBV AFFlRM UNDER PENAL7V 4F PERJURY ONE OF TNE FOLLOWING DECUFATIONS: � � Z Q O iHAVEANDWIlLMA1NTAIMACERT,FICATEOFCONSENTTOSELF-IN6UREFORWOPNERS' S (`,OMoE AS PROVID6D BY SECTION 170o OFTNE LABOR CODF,FOH THE PERFORMANCE U 4 O ORK FURYdFi1CH THIS PERMIi IS ISSUED. �' I.I.d IHAVEAN�WI�IMAINTA1NWOqNERS'67MPENSATiONINSUR CE RE�UIREDBYSEGTION � 37000FTHELA80 FORTNEP�pFORM FTH OR flWNIC ERMITIS 155UED.MY W0 ERS' PENSATION INSU NC� R UCYN BER RE: CONSTRUCTION ycARRieR_ PLAN REVIEW � pOLICYNUMBER __ _ ELECTRIC a Q m+ss[cnor�nEex�re=_o�wt'�oovn+��rwrrsFo c�NeFn�'�or� s�:sirol��Ess� PLUMBING • W MECHANICAL � I CERTIFV T{;AT IN THE PFRFORMRYCE OF TH PK F H T PE M IS ISSUEO.I (�3' SHALLNO7EMaLCYANYPERSONINANY JN[R �CO UB TTOTI�.E � WORNERS'CO/APENSATIONLAWSOFC IF , ET T IS L�BECDME INSPECTIONFEE � SU&IECT TO THE WORNERS'COMPEN9 N P I NS N 3� OF 7HE LABOR CODE,I SHALL FORTHW H COMPLV WI -HO I IO S ISSUANCE � SMIP p DATE:�� APPLICANT; ` . J ENERGY P/C J WARNING:FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFVL,ANOSHALLBE � SU&IECTANEMPLOVERtOCqIMINAlP6NALTIESANOCNILFINESUPTOONEHU4DRE0THOUSAN� ENERGYPERMIT DOIUflS(f100.0a0�.IN ADDITION TO TNE COST OF COMPENSPTION,DAMAGES AS PROVIDEO FOR IN � SECTpN97oBOFiHEIABORCOOE.INTEREST,ANOAT?ORNEY'SFEES. RETENTIONFEE: � CONSTRUC710N LENDING AGENCY PRE-ALT FEE: L� I HEREBY AFFIRM UNDER PENALTV OF PERJURY THATTNERE IS A CONSTRUCTION IENDING AGENCV Q FOfl THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3oB],CIV.C.�. Z ld,i � LENDER'SNAME F- IENOER'SAO�RESS ��9 � ICERTIFVTHATIHAVEREADTHISAPPUCA ANOSTATETHA7THEABOVEINFORMATIONISCARHECT. TOTAL FEES 6X r W i AGfiEE TO CAMPLV WRNALL CITY ANO UN Y ORDINANCES ANO STATE L4WS PEIATING TO BUILOING � GONSTRUCTION,ANDHEPEBYAU I RE RESENTATIVESOFTHISCOUNTVTOENTERUVONTHE ZAgOVE• TIONEDPFO�ER N ECT NPURPOSES. COMMENTS � ��,�j �e � � PEHMITT NAIA (r ¢ � � �� U) - � SIGNATURE O PE M OATE � RECPT NO. 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