No preview available
HomeMy WebLinkAbout15103i _ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 WELDING PERMIT APPLICATION JOBSITE ADDRESS .l !V 1J APN LOTTFj(4CT OWNER A 3 o P. ADDfl SS IV"�� CrrY J` -A t;;t4k. %C- ZIP APPLICANT TEL CONTRACTOR 3 v ADDRESS itv CITY Qrl rr'LO/J� ZIP?ARCKENGf TEL DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U - CENSE UW FOR THE FOLLOWINO REASON (SEG 7031.6 BUSNESSAND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REOURESA PEFMRTO CONSTRUCLALTER IMPROVE. DEMOUSH,OR REPAIR ANY STRUC. TURE PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISO NS OF THE CONTRACTORS LI. CENSE UW (CHAPTER I (COMMENCING WnTH SECTION 7000) OF DMSION 3 O THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT LIORE THAN FIVE HUNDRED DOLLARS (SSW).): O LASC MEROFTHEPROPERTY,OR MV EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". BUSH NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS ORIMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR THRIXIOH HIS CANER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF. HOWEVER,THE WILDING OR IMPnOVEMENT 15 SOLD WITHIN ONEYEAROF COUPLE - TION. THE OWNERAUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR DIE PURPOSE OF SAL" O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS 70 CONSTRUCT THE PROJECT (SEC. 704A, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI. CENSE UW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE COWPAC- TOFS UCCNSE LAW.). O 1 AM EXEMPT LINDER SEC. B. A P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I NEREBY AFFI AI UNDER PENALTYOF PERJURY THAT IAA LICENSED UNDER PROVISIONS OF CHAPTER M (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS N FULL FORCE AND EFFECT. ` LICENSE SS q< LIC. NO. Qt/ DATE Z CA CONTRACTOR WORKERS' COMPENSATION DECLARATION j I HEREBY AFFIRM LARDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELFJNSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT D ISSUED. .(�1 HAVE AND WILL MAINTAIN WORKERS' CONDENSATION INSURANCE, AS PE WIRED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMDER ARE: CARRIER L7 T "� W-0 J=� ✓ Nj> POUCYNUMeER -I q r �► ' (THIS SECTION FEEDNO'TBE CU.PIEMD OF THE PERMIT 6 FOR ONE HIMORCD Lll.;.' 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 61SSUED.I SHALL NOT EMPLOY AM7 PERSON N ANY MANNER SOAS TO BECOME SUBJECTTO THE WORKERSCOMPENSATIONLAWSOF CALIF RNIA,ANOAGREETHATIFISHOLLOBCOOME SUBJECTTO THE NORKERS'COMPENSAT DROVISKX)S OF SECTION 37DO OF THE LABOR CODE, • FORTHVATH COMPLY WI SE PR IONS. DATE: 2 V APPLICANT. i WARNING: N FAILURE TO To CR WORKERS'ALLIES EN ION COVERAGE IS ONE HUNDRED D SHALL BE THOUSAND SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FIVES UP TO ONE HUNDRED THOUSAND DOLLARS 13100.000). N To TO THE C057 OF COMPENSATION, DAMAGES AS PROVIDED FOR IN i SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. 1 CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. C.). i LENDERS NAME LENDERSADORESS i 1 CERTBY IO THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. i i 4PERM0- EE E(PaNn /11 LS Zy S1GkATdhE O Tr o E PRESS FIRMLY APPLICATION �J_-3 P /CvV •�b DATE NUMBER ✓ lS—DvPERMT ISSUTYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW Q REAR Q SIDE(SIDESTREET RW Q SIDE ❑ PROPOSED USE'1AJ'NTA Vl— I N 0 Nr% , NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREANALUATION SFR/AOD/REM U) Garage/Carport WPatio/Deck V- PODUSpa ZRe -Roof 0 Commercial - m Valuation ADJ.AREA OUANTITY DESCRIPTION FEE .,1 U K F- U W LU LU Z CO d Q U 2 a x U W 573 0 CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING ?'* MECHANICAL INSPECTION FEE ISSUANCE�I—rr�_ U SMIP >� 'r r' lr(�, ENERGY PIC ? ^ * - ENERGY PERMIT RETENTION FEE: ST,u JAF,7:. ��3� !�U PRE -ALT FEE: TOTAL FLEES �� COMMENTS V � L et � - ��L�/� RECPT�� PAID BY VALIDATION WHITE—Department Copy. YELLOW --Finance Copy, PINK—Assessor Copy. GOLDENHLJU—Fele UOM GHLEN—AppRcent-S (;opy