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HomeMy WebLinkAbout16134 (22) .� ��'��� _�� CITY OF DIAMOND BAR �,,. , DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES ,� 3 d C7 � � 216b0 E.Copley Drive 3uite 190 (909)860-3195 Faz(909)861-3117 PRESS ''��°"` BUILDING PERMIT APPLICATION FIR LY _ _ y JOBSITE [,� APPLICATION.. j �,; � PERMIT P/C o ADDRESS ���� C�� �JOU Ir I�L I�'� DATE { X% NUMBER r � � APN LOT TRACT �SSUE TYPE , CC p OWNER � (� DATE CONST. GROUP �p ADDR SS G? 4� 1� Y. ZONING SETBACKS � CITY � Gf t7i3 r' ZIP ' TEL �1 � . '�I 1�'� FRONT qyy p APPLICANT l,iTE - 1�"�S f S'-131�i REAR p � SIDE/SIDE STREET RW ❑ CONTRACT 17� f�SP' SIDE � � ADDR SS � -�. 2^ t,vC,a CITY Gt ' !` ZIP���� >TEL�d�J S/�'I�i II PROPOSED USE o ARCWENG! � DESIGNER — NO.DWEL. NO. Np, ADDRESS �n UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p OWNER•BUILDER DECLAAATION SFP/ADD/REM [] i HEREBY AFFlRU UNDER PENALT'OF PERII�RY THAT I AM EXEMPT FROM THE CONTRACTORS LI- W CENSEUWFOqTHEFd.LOWiNGREASON�SEC.7o31.58USINE6SANOPROFE5510NSCODE:ANYCRYOR � Garage/Carport S2 COUNfVWFIICHREOUIRESAPEqMITTOCONSTRUCT,µTER,IMPROVE,DEMOLISH,ORREPAIRpNYSTRUC- W Petio/DBGk W TURE.PRIOH M RS ISSUANCE,ALSO REIX11RE5 THE APPLICAN7 FOq SUCH PERMIT 70 FILE A SIGNED W � STATEMENf THAT HE Ofl SME IS LICENSEO VURSUANT TO iHE PqOVI510NS OF THE CONTRACTORS LI- � CENSE UW(CHAFTER Y(COMMENCINO WITH SECTIpN 7000)OF DNISION 3 OF THE BUSINESSAND PRO- LL POOI/Sp8 FESSIONSCODE)ORTWITHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (!3 iION.ANYVI0UTI�NOFSECTION7037.68YANYAPPUCANTfORAPERMITSU&IECTSiHEAPPLICAN7T0 z Re-Rpof F, �CIVIL VENALT!Of NOT MORETHAN FNE HUNDRED DOLIARS(S5oD7.): � ❑I.ASOWNEROFTHEPROPEH7V,ORAAVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSAT�ON, 0 Commercial WILL DO THE WORK,AN�THE STRUCTURE IS NO7INTENOE�OR OFFERED FOR SALE�SEC.)04a,BUSI� .J � NESS NJ�PRpFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPEHTY WFIO 6UIlDS OR IMPROVES THEREON,AND NMO DOES SUCH WORK HIMSELF OR HERSELf OR � THFi0U0FiHISORHEHOWNEMPLOYEES,PHOYI�EDTHATSUCMIMPROVEMEMSAqENOTINTEN�E�OR � O OFfEREOFORSILLEIF,HOWEVERTMEBUILDINGORIMPqOYEMENTIS50LDWITHINONEVEAROPCOMPLE- '� TION.7HE OWNER-BUILDER WILL HAVE TME BURDEN OF PpOVINO THAT HE OR SNE 010 NOT BUIIA OR IMPROYE fORTHE PURPOSE OF SALE). ❑I,hS OWNER OF TNE PRQPEP.T1;AM ExCLUSIVELY CANTRACtINC WITH:ICENSED COMRACTORS TO CONSTRIJCT THE PRQIEC7(SEC.�041,BU5MESS AND PROFESSIONS CODE 7NE CONTRACTORS LI- ValUBtion ADJ.AREA W CENSE UW DOES NOTAPPLYTOAN ONrtJER OFA PROPERTY WHO B111L�5 OR IMPROVES 7HEREON,AND � WFIOCOMRAGTSFORSUCNPROJECTSNAlHACOM'qAC70R(S)LICENSEDPURSUMlTTOTNECONiMC- QUANTITY DESCRIPTION iORSIJCENSELAW.). FEE 0 O I MI EXEMPT Ut�DER 6EC. B.d P.C.FOR TNIS RE4150N Q � U LL DATE _ OWNER � � � U LICENSED CQN7AACTORS DECLARATIOPV W � I HEqEBY APFIpM UNOER PENALTY OF PE0.RIRY TNAT 1 M1 LICENSED UNDER?ROVISIONS OF CHAPTER �, � � � � G(COMAIENCING VATFI SECTION 7000)OF DIVISION 3 OF T4E BUSINESS AND PROFESSIONS CODE,AND Z ��� MY IICENSE IS IN FlJLL fORCE M!D EFFECT. m ��7`� � � UCENSE CLASS.���✓�LIC.NO.�K ��S �_ � V DATE__ CONTRACTOR C31� � -: d W � WORKERS'COMPENSAYION GECJ�RATION a � 1HEREBYAFFIRMUNDEflPENALTYOFPERJURYONEOFTHEFOLLOWINGOECLAqATIONS � � � Z � _IHAVE/WDWILLMJJN"IAINACERTI�ICA7EOFCANSENTTOSELF�INSUflEFORWbRKERS' d ,��- COMPENSRTfON,AS PROVIDED BY SECTION 3700 QF 7HE I.ABOR CODE,FbR THE PERFORMANrE U� � OF 1FIE WORK FOfl WHICN 7NIS PERAIIT IS ISSUF�. � � _I HAVE AND W%1 MpINTAIN WORKERS'CO:APENSATION INSURANCE,AS REOURED 8V SECTION Q 37000FP.1ELAAOqOJDE,F(1RTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMIT'�S ,�,,� ISSUEO.MY WOHK RS'�MPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTIDN } CARRIER���"��yC.�_�.�y...,� PLAN REVIEW � POLICY NUk'iBER_l`Z�..(�C3 1 '�'�V��__ ' ELECTRIC � (n��ssEcrrx�N�r�oroEcce.sr.ETrna"r�xw.srrsroaorieHur�mwuaRs�Eiao)oa�ess). PLUMB�NG _ � � ICER71FV7HA71NTHEPER�ORMANrEOFh1EWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL ._ 1 SHALL NOT EMPLQY ANY PERSON IM ANY MANNER SO AS TO BECOME SUBJEC7'70 TNE " (A WORKER5COMPENSATIONlAW50FCALIFORNIA.ANUAGFEETMATIFISNOl1tD9Ec�ME INSPECTIONFEE � SUBJECTTOTHF.WORKERS'COMPENSATIONPROv�SIONSOFSEC710N37000FTliEL480R CAOE,I SHN1 FORTHWITM COMP_V WITH THOS'yE�PROVISIONS. 1 ,p��. ISSUANCE p DATE: ,_ APPLICANT. C-T ~ l 1��.CJ�C''�J SMIP _ I.tJ J WARNING FAILURE TO SECURE WORKERS'CQMPENSpTiON COVERAGE IS UNLAWFl1L,AN�SHALL 6F ENFRGY P!C - LL SU&IECTANEMPLOYEflTOCRiMINALPENALTtESANOC!ViLFINESUPTOONEHUN�REDTHOUSANO ENERGYPERMIT DOLLARS(f100.0ao).IN MDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 3708 QF lHE LABOR CODE,INTEREST;ANDATTORNE`/'S FEES. RETENTION FEE' OCONSTRUCTION LENDING AGENCY PRE-AL7 FEE: � t HEREBYAFFIRM UN�ER PENALN OF PERJURV THAT THERE IS ACONSTRUCTION LENOING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERIAIT IS ISSUED(SEC.3n97,CIV.C.). Z W � LENDER'SNAME_ __ — F— LENDER'SP.DORESS � � � W 1 CER7IFY THAT I HAVE REW THIS APPUCAT!ON AND STATE THA7 THEABOVE MFORMATION IS CARiiECT. TOTAL FEES .� � I AGREE TO COMPLY W1TH ALL CIN AND C�UNTY OROINANCES AND STATE LAWS RELATING To BUIL�ING � CONSTRUC710N,ANDHEREBYAUTHORIZEREPRESENTA7IVESOFTHISC011N1Y7oENTERUPONTHE Z ABOVE-MEMKKJEDPROPERTYFORINSPECTIONPURPOSES. 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