HomeMy WebLinkAbout16104 (9) I -
' ` f� CITY OF DIAMOND BAR '
� DEPARTMENT OF COMMUNITY 8�DEVELOPMENT SERVICES
' 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
� ��'„" BUILDING PERMIT APPLICATION ���SS� c_s �,,� 3(r FIRMLY
� JOBSITE 'r APPLICATION C � PERMIT � L P/C
o ADDRESS ���I G� CIl/)yC���I V t S� DATE � I '"� � NUMBER� #
� APN LOT 9 3"v� TRACT S��`� �SSUE TYPE OCC
DATE CONST. GROUP
p OWNER
o ADDRESS��+LdI O•1 �I^MA^ ZONING SETBACKS
W CITY rp/lII"L�':�.--_ ZIP Zb�t- TEL. � �17" YC FRONT qyy �
� APPLICANT �,�ct.�►4� TEL. c��Y► REAR ❑
� SIDE/S�DE STREET RW ❑
CONTRACTaR �/ ` M I'P SIDE ❑
� ADDRESS v � 4
CITY �YV tl�lY� ZIP�{L TEL.R`��i-�r4 Y cca PROPOSED USE -►2
z� ARCH/ENG/ q� ��
DESIGNEFi�{�r o+ �r�SS c�' �' NO.DWEL. NO. NO.
� ADDRE S �� /� UNITS STORIES BEDROOMS
N CITY re��IP�,f TEL.��_/-SS�-�t�711
cn DESCRIPTION SQ,Ff. FACTDR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
O
p I HEREBY AFFlRM UNDER PENALiY OF PERJUR'/THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gflfaye/C2fpOlt
� CENSEUWFONTHEFOILOWINGREASON(SEC.70.71.5BUSINESSANDPPOFESSIONSCO�E:ANYCI7VOR (n
COUNTYNMICHREOUIRESA�ERMITTOCONSTRUCT.ALTERIMPROVE.OEMOLISH.ORREPAIRANYSTRUC- W PdtlO/DBCk
NflE VRpR TO ITS ISSUAIVCE,ALSO REOIlIRES 7HE APVIICANT FOR SUCH PERMIT TO FILE A SIGNED w
STATEYENT TH►T HE OR SNE IS LICENSED PURSUMfT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE UW(CHA�TER V(C(MIMENCING WITH SECTION�0[W)OF DIVISk�N 30F THE BUSINESS AND PRO- u' POOVSP2
FESSIONSCODE)ORTMA7FIEORSHEISEXEMPTTHEREFROMPNDTHEBASISFOPTHEALLEOEDEXEMP- (�
TqN.ANYYKKA710NOFSECTION703t.5BYANYAPPIICANTf-0RAPERMIiSU&IECTSTHEAPPLICANTTO Z Re-Roof
� AqVIL PENALTY OF NOT MC)RE TNAN FIVE HVNDRED DOlURS(f5a0).):
^ ❑�.ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITFIWAGESASTHEIP50�ECOMPENSATION, ❑ COf11R1efC181
� WILL DO 1T1E WORK,N7D TIiE STRUCTURE IS NOT INTENDED OR OFFERE�FOF SALE�SEC.701d,BUS6 J
� NE55 AND PROFESSIONS OUDE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPERTV WF10 BNLDS OR IMPROVES THEREON,AND VMO OOES SUCH WORK HIMSELF OR HERSELF OR
2 THIiOUGH HIS OR HER OWN EMPLOVEES,GROVIOED THAT SUCH IMPROVEAAENTS RFE NOT INTENDED OR CD
Q OFFEREDFORSALE.IF,HOWEVE0.7NEBUILDINGORIMPROVEMEMISSOLDWITHINONEYEAROFCAMPLE-
Z TqN,THE OWNER-BUILDEF.WILL HAVE THE BVFDEN OF�ROVING THAT HE OR SHE DID NOT BUILO Ofl
� IMPROVE FOR THE PURFOSE OF SALE).
W ❑1,A$ONMEfl OFTHE PflOPEHTY,AM EXCLUSIVELYCANTflACTMG WRH LICENSE�CONTRACTORS
� TO CONSTRUCT THE PflQIF'CT(SEC.1oN,BUSINE55 MID PROFESSIDNS CODE'THE CONTRACTORS LI- VflIUHI1011 AOJ.AREA
W GENSEUWWESNOT�PPI.YTOMlOYMEFOFAPROFERTYWHOBUILOSOflIMPROVESTHEFEON,AND —
� W/qCONTRACT5WR5UCNPRQIECTSWITHA('X7NTFiACTOfl(5)LICFNSEDPURSUANTTOTHEWNTRAG QUANTITY DESCRIPTION FEE
Y TORS LICENSE UW.). _
Q ❑I AM EXENPT UNDER SEG __B.8 PG FOP THIS FEASON Q
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w�Te OWNER r
U
W
� LICENSED CONTRACTORS DECLARATION W
� I NEREBYAFFIfUI UNDER PE:NALTY OF PERJUqY THAT 1 AM UCENSED UNDER PROVISIONS OF CHAPTER �
d Y�COMMENCWO WRH SECTION 7000)OF DIVISION 30FTHE BUSINE55 AND PROFESSIONS CODE.AND Z
X MV LICENSE IS IN FUIL FOR��E D EFFECT m
u�
� LICENSE CLASS__.. LIC.ND. �
U OATE ����I'���_ CONTRACTDR 4� � d
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRY 1/NOER P[NALTV Oi VER1lIRV ONE OF THE FOLLOWING DECLARATIONS: Z
O __I MAVE AND WILL MI,INThIN ACERTIFIGATE OF CONSENT TO SELF-INSURE fOR WORKERS' a
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Q COMPENSATION,�5 PROVIDED BY SECTION 3�00 OF THE UBOR CODE.FOq THE PERFORMANCE U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
I
W _1 HAVE AND WILL AII.INT�IN WORKERS'COMPENSATION INSURANCE,AS REQl/1RE�BY SECTIDN
O 3iU0 OF THE LABOR CODE,FOR THE PERFORMANGE Of TME WORK FOfl WMICH TMIS PEaM1T IS
ISSUED.MY W KERS'CCMPENSAT�ON INSURANCE CARRIER AND POLICY NUMBER/�flE: CONSTRUCTION
_! ��r /�-
j CARRIER ♦�IJ laar__j.��. PLAN REVIEW
� �icr NUMeER__ t� ,�gJ/�•! 'g� ELECTRIC
Z
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� (iviiSSEcfpMNEmW078Eachs�E7E0oF'n1EaEar.MrlSF�aoNE�-�lu�[MiE�oaLu�s(E�m)cqtEssy PLUMBING 1 .� � __
Z1 CERTIFY THAT M fHE PERFORMqNCE OF THE WONK FOq WHICHTHIS PERMIT IS ISSUEU,I MECHANICAL _
(,�J SNALL NOT EMPI D1'ANY PERSON IN ANV MANNER SO AS TO BECAME SVBJECT TO THE -
� WORKERS'COMPEPISATKKJ lAWS OF CALIFORN10.AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE __.____
SU&IECT TO THE WORKERS'COMPENSATION PPOVISION5 OF SECTIIXJ 370o OF THE LABOfi \
� COOE,I SHALL FOR'fHWtTH COMPLY WITH OSE PROVISIONS. /`' �SSUANCE ��y-� ,IJ�+�
� -/-=1��t �_:1�.�_M�'�
p l)ATE. APPLICANT'. V ••� (p SMIP _
J WARNING:FAILURETO SECURE WORKEHS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALLBE ENERGY P/C _ _
�y SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPEFiMIT
�OLURS(5100,000�,IN M�ITION TO THE COSTOF COMPENSATION,DAMACES AS PROVI�E�FOR IN
J SECTION 3]oe OF 7NE UBGR CODE,INTEREST,AND ATTORNEV'S FEES. �
¢ _ RETENTION FEE: ___
OCONSTRUCTION LENDING AGENGY PRE-ALT FEE:
� I NEREBV AFFIRM UNDEq PFNAL7V OF PERJURY THAT THERE IS ACONSTHUCTION LENDING AGENCY
FOR THE PERPoPMANCE 01=THE WORN FOR WHICH THIS GERMIT IS ISSUED(SEC.3o97,C V G�.
W . A
� LENOER'S NAME IV��N � ✓ � S � __,
F— LENOER'SADDRESS
¢ ICERTIFYTHATIHAVEREADi111SAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES .1 � �,�
W I AGHEE i0 fAMPLV WITH PLL CIT'AND COUNTV ORDINANCES AND STATE LAWS RELATING TO eUILDWG �'
d
� CONSTRUCTION,AN�NEREBV AUTHOPoZE REPRESENTATIVFS OF THIS COIINTV TO ENTER UPON TNE
Z ABOVE�MENTIONED PROPERTY FOF INSPECTION PURPOSES.
� COMMENTS
J
� _
m PERMITTEE NAUE(PRINT)
Q
�
� SIGN�TVFEOFFERMITTEE DATE
= RECPT.NO. PAI�BV VALIDATION
~ WHITE—DeDartment Copy,YELLOW—Finance CoVX PWK—Assessa Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY� DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
�.ss t�=S Pla.n 3
PRESS
FIRMLY
JOBSITE
' r
ADDRESS��?ILI ��JG��I Uts'F�.
APN LOT 9 3--yv TRACT.��,'
OWNER
ADDRESS1�dI Crl MMAn
CITY r�,,�;
ZIP Zb�L TEL. � �17"YC
APPLICANT,�d,�-�-�TEL.GSM
CONTRACTOR/M �'P
ADDRESS v CC it
CITY�YVtt�ZIP�L TEL.9�j�t-�r4YCC�
ARCH/ENG/
DESIGNER�rt+SS tt�SC(
ADDRE S"�-t/S A�
CITY��ZIP�,�TEL.��/-.SS-�-��7
OWNER-BUILDER DECLARATION
I HEREBY AFFIFtI.I UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE Fg10 WING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CI7V OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER.IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE, PRK)R TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT T1iAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTFUCTORS LI-
CENSE UW(CHAPTER B(COMMENCING WITH SECTK)N 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSK)NSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOP THE ALLEGED EXEMP-
TqN.ANV VKXATKKi OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(S5oo)J:
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7066,BUSK
NESS AND PROFESSIONS BODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE N07 INTENDED OR
OFFERED fOR SALE IF,HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TKkI,THE OWNER-BUILDEF.WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OVMER OF THE PROPERTY AM EXCLUSIVELY CONTRACTING WRH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7oN,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAG
TORS OCENSE UW.).
^ I AM EXEMPT UNDEFI SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LII�ENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTKNd 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FOPCE D EFFECT.
LICENSE CLASS -� LIC. N0.
DATE I'��II'-��CONTRACTOR Ls
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PF:NALN OF PERJURY ONE OF THE FOLLOWING DECURATK)NS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATKOJ,AS PROVIDED BV SECTION 3700 OF THE LIBOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY W KERS'COMPENSATION INSURANCE CARRIER AND POLICY
NU
M
BER RE:
/
I'
CARRIER
v Il.y�� „
/
POLICY NUMBER_� r��� �'/•g
(n'OS SECfpN NEED IJOT BE OJA�PLETE-OFTHE PEFY.YT IS FOR ONE HIN�DIiED DCILARS(Ei W)OH LESSy
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEU,I
SHALL NOT EMPI OY ANY PERSON IN ANY MANNER SO AS TO BECOME SVBJECT TO THE
WORKERS'COMPEFISATKXi LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 qF THE LIBOR
CODE,I SHALL FOR'fHWiTH COMPLY WITH T OSE PROVISIONS.
DATE:.j--1�-01_APPLICANT: �V�'���-�G-ra-
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLURS(5100,000),IN ADDITION TO THE COST OF COMPENSATKN,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE UBGR CODE,INTEREST,AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMAN
CE
01=T
H
E WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,C V C.).
)
A
LENDER'S NAME,V t�Ir�/�v� ��
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATgN IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF FERMITTEE DATE
WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy