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Home My WebLink About17012 (25) , CITY OF DIAMOND BAR � " — --�` - DEPARTMENT OF COMMUNIT'Y&DEVELOPMENT SERVICES � � 21825 E.Copley Drive (909)&60-3195 Paac(909)&61-3117 Pf;Es$ '`'%.q�a'� BUILDING PE IT APP ICATION FIRMLY � JOBSITE APPLICATION� 1� D ( PERMIT `� � P/C /� _� o ADDRESS_ F� DATE_ NUMBER � # v ' o ISSUE TYPE OCC -c-° APN .�+�'k-' LQT RACT��T I� DATE � CONST. GROUP p OWNER �L�� '�°'et ' K Se�WV� ADDRESS I�� iYc'7.� �yr��a�,� ZONING SETBACKS Z CITY . 'IP TEL:�' FRONT RW ❑ o APPLI ANT 3 _ TEL.G(�?��i`�� S DE/SIDE STREET RW ❑ z ¢ CONTRAC OR � �1 f SIDE p � CDDRESS Z TEL. � PROPOSED USE �'A�!�!9� __ �7� `Z ��Z��-'v'1 O ��--�� w ARCH/ENG/ �L�� `�'—T �_ �`�� z DESIGNER �r r��i NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY TE�. cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADDlREM O I HEREBY qFFIRM UNDEF PENALTV OF PERJUFY THAT I hM EX'cMPT M iHE WNTRACTORS LI� G&/&96/CBfPOfI �W CENSELAWFORTHEFOLLOWINGREASON(SECJ031.SBUSINESSANDP ESSIONSCO�E:ANYGTYOR (n U COUNTYWHICHREDl11RESAPERMITTOCONSTRUCT,ALTER,IMPROV EMOLISH,ORREPAIRANVSiRUC� W PatiO/DBCk TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPI.ICAN OR SUCH PERMIT TO FILE A SIGNE� W STATEAAENT THAT HE OR SHE IS�ICENSEO PURSUANT TO T ROVISI�NS OF THE CONTRACTORS LI� W � CENSE LAW(CHAPTER B(COMMENCINC.WITH SECTION 7 OF DIVISION 3 OF THE BUSINESSAND PRO- � POOIISpB FESSIONSCODE)ORiHATHEORSHEISE%EMPTTHER OMANDTHEBASISFORTHEALLEGEDE%EMP� � � TION.ANYVIOIATIONOFSECTION7o31,58YANYAPP ANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof ACIVILPENPLTYOFNOTMORETHANFIVEHUND DOLLAiiS(E5ao).): Z ❑I,ASONTlEROFTHEPROPERiY,ORMY PLOYEESWITNWAGESASTMEIRSOLECOMPENSATION, � COfTIR1BfC18I WILL�0 THE WORK,AND 7HE STRUCTURE NOT INTENOED OR OFFERED FOR SALE(SEC.7044,EU51� J � NESS AND PqOFESSIONS CODE:THE CO ACTORS LICENSE LAW DOES NO7 APPLY TO AN OWNER OF � PAOPEHTVWHOBUILDSORIMPROVE EREON.ANDW-IODOESSUCHWORKHIMSELFORHERSELFOR CC 7HROUGHHISORHEFOWNEMPLO S,PROVIDEOTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR m QOFFEREDFORSALEIF,NOWEVE EBLIILDINGORIMPROVEMENTIS50LDWITHINONEVEAPOfCOMPLE� z TION,THE OWNER-BUILOER W HAVE THE BURDEN OF PROVING THA7 NE OR SHE DID NOT BUILD OR � IMPROVEFORTHE?URPOS FSAIEJ, W ❑I,ASOWNEROFT PROPERTY,AMEX0.USIVELYGONTRAGTIM1GWITHLIGENSEOGONTflACTORS Q TO CONSTRUCT TFIE P JECT(SEC.�049,BUSINESS ANO PROFESSIONS COCE:THE CON7RACTOFS LI� V2IU2IIDf1 P"� ADJ.AREA W CENSEIAWDOESN 0.PPLYTOANOWNEROFAPFOPERTYWHUB�JI'�_DSORIMPROVESTHEREON,AN� -- � WHOCANTRACTS SUCHPROJECTSWITHACONTRACTOR(S)UCENSEDPUFlSUANTTOTHECONiRAO QUANTITY DESCRIPTION FEE Y TORS LICENSE .). ' � ❑I A EMPT UNOER SEC. B.R P.C.FOR THIS REASON Q �� .t_�.S � � ' ----_—__—'_-- _ _'___—''.._________...__.'__ � � ��.� r��)� zDAT OWNER � � L�S W `� ¢ LICENSED CONTRACTORS DECLARATION W OC I HEREBVAFPoFM UN�ER PENALTYOF PEFJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER �, d 9(COMMENCINGWITHSECTION7ooa)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z LX MV UCENSE IS IN FULL FOFCE AND EFFECT m � LICENSE CLASS LIC.NQ �4( � � � j � J U DATE CONTRACTOR C.LZ _ a W � WORKERS'COMPENSATION DECLARATION -� 4 � 1 HEREBV AFFlRM UNDER PENALTY OF PERJURV ONE OFTHE FOLLOWING DECLARATIONS: Z 2 _IHAVEANDWILLMAINTAINACEftTIFlCATEOFCONSENTTOSELF-INSUREFORWORKERS' _ ¢ COMPENSATION,ASGROVIDEDBVSECTION37000F7HElA80RCODE,FOR7HEPERFORMANCE U OFTHE WOFK FOR WHICHTHIS PER611T IS ISSUED. � � I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION f e-y'-, Q 3�0o OF THE U180R CO�E.FOR THE PEP.FORMANCE OF iHE WORK FOR W ICH THIS PERMIT IS (p CJV ISSl1ED.MY WORKERS'Cc�iPENSATION ISURANCE CABAICi�4ND POLICY UMBERARE: CONSTRUCTION I��{� ¢ � /'✓- � CARRIEF uFj �`y�//�V___ PLAN REVIEW _._. D Z POLICV NUMBER� 1�I��.7�^� `C�l ELECIAIC Q � (IHISSECTNNJNEmNOTBECOMPLEfmOFTHEPERMTISF-0RIXJEHIA�[NiEDDIX.IMS(5100)ORL�S). PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OFTHE YlCRK FOR ICH THIS PE IS ISSUED,I MECHANICAL C7 SHALLNOTEMPLOY0.NVPERSONINANYMANNERSOAS BECAME TTOTNE � WORKERS'COVAPENSATION LAWS Of CALIFORN� N REE TH HOULD BEC(�A E INSPECTION FEE SUBJECTTO HEWORKERS'COMPENSATIONP I NSOFS N3�o00FiHEL�O � COO SH FORTHWITH COMPLV WIT:1 THO VISION ISSUANCE � �U � ,�'r SMIP � " �� p DATE: APPLICAIVT: J WARNING:FAIL ETOSECUFEWORI(ERS'C SATI NCOVEaAGEISIJNLAWFUL,ANDSHALLBE ENERGYP/C �y SUBJECTANEMPL�YERTOCRIMINALPENAL ANOCNILFWESl1PTOONEHUND�9E0THOUSAN� ENERGYPERMIT DOLLARS�51oa.000),INADDITION TOTHE C FCOMPENSATION,OAMAGESAS PROVIDEO FOR IN r—�— � SECTION 3]08 OF THE LABOR CODG,INTC sT,nNo nTroaNers Fees. RETENTION FEE: UV d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBVAFFIFN UNOER PENALTV OF PERJl1RV THATTHERE IS ACOy$ N LENDING AGENCY FORTHEPERFORMANCEOFTHEWORKFORVlHICH AR"S'fS`SUED(SEC.309t.CIV.CJ. �` -t� z N N W � LENDER'S NAME _ O F_— LENDER'SADDRESS ' j }}}` � I CEflTIFV THA'.I HAVE READ THIS APPLICATION AND STATE THAT THE ABOYE INFORMATION IS CORRECT. TOTAL FE ES..-�...,, �� `�� J w I AGREE TO COMPIY WITH ALL TY AND CO Y ORDINFNCES AND STATE LAWS RELATMG TO U DING �(�Q •�O � CONSTRUCTION,AND HEFI�BV 6R�Z EPRESENTATNF.S OFTHIS COUVTYTO ENTEfl UP HE � ABOVE-MENTIONEO�qOP�[iTV R I ECTION P R�OSES. � �' Z COMMENTS _ 0 � � m PERMITTEE NA `` ¢ /V � � � SIGNA EE DAT = RECPT.�O. PAID BY VALIDATION ~ WHITE--De arlment Co YELLOW—Finance C p py, opy,PINK—Assessor Copy,GOLDENFOD—File Copy,GREEN—Applicant's Copy '.', .,,}.,:,ti, 1 {y�:�;i;� ��.,,..,,`,M .4t�'�JS-:`a¢- �`,:f:�., x rg, : . .a;. ..>?�w.N ,ua;. 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