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HomeMy WebLinkAbout16122 (39) - - _ ----- -- -- - - - ,__-- �� ��?�. ��� � CITY OF DIAMOND BAR �-'�-_ � DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES `' 21660 E.Copley Drive Suite 190 , ``�/ (909)860-3195 Fas(909)861-3117 PRES$ 9�`"`` BUILDING PERINIT APPLICATION � y �, �; FIRMLY � J08SffE �7 /� APPLICATION PERMIT +�^ i P/C 1'�� o ADDRESS 4�l:�I� ��(16�fT i���-� DATE �y���� NUMBER�� � �"' ��" � ISSUE TYPE OCC APN LOT � " � TRACT K'�`,���I_ pATE CONST. GROUP ' p OWNER �'- ADDRESS ZONING SETBACKS � CITY ' ZIP �(EL. ' REART Rw a APP4ICANT TEL. SIDE/SIDE STREET RW ❑ � � CONTRACTO SIDE ❑ ADDE;ESS pROPOSED USE i`�+'�P'Mt.: O CITY " ZIP TEL - w ARCWENG/ � � DESIGNER i � NO.DWEL. NO. NO. � ,'ADDRESS � #' UNITS STORIES BEDROOMS y ' CITY��„r�'�'°�?IP EL.����� � DESCRIPTiON SQ.FL FACTOR PS ADJ.AREANALUA ION a ' �WNER-BUILDERDECLARATION SFR/ADD/REM ' �, p � I NEREBY AFFIFM 11NDER PENALTY OF PERJURV THAT I AM EXEMFT FROLt THE CONTRACTORS LI� G8Ia9@/CB�pOR '�`j"� ,��J'-�.�'.i I W CENSELAWFOHTHEFOLLOWIN�RE�(SEC.7037.5BUSINE35ANDPROFESSIONSCODE:ANYCITYOR (n , C] '�,.COUN7VWHICHRECHJIRESAPERMITTO',C045TAUGT.AL,7EH,IMPNOVE,DEMOLISH,ORPiEPAIRANYSTRUC• W P8ii0/DBCk � '�,TURE,PRIOR TO ITS ISSUANCE,PLSO RE�UIPES THE APPLICANT FOR 6UCH PERMIT TO FllE A SIGNED W � ',�STATENEN7 THAT HE OF SHE IS'LICEhSEO PURSUANT TO THE PROVISIONS OF THE WNTRACiURS U• . . �,�CENSE LAW(CHAPTER9(CQMMENCING WI7H SECTION 7090j OF DIVI510N 30FTHE BUSINESSAND PFD- 'u" PooUSpa I FESSpN5(X7�E�ORTHATHEOR�SHE1$E%EMPTTHEREFROMAND7HEBASISFOFTHEALLEGEDE%EM1iP� ��. ��.TI@1,ANVVIOLATIONOFSECTIOt;IT031�59YANYAPPLICANTFORAPERMITSUBJEGTSFHEAPpLICANTTO �� RB-R00� � - � .AqVILPENALTVOFNOTMOFET}IANFNEHUNDREO�OLLAflS(E500)J: , ^ , ❑I,A50WNEROF7HEVROPERTY,�.ORMYEMPLOYEESWITHWAGESASTHEIRSOIECAMPENSATION, � ComfPl9fCi81 ' � '���WILL 00 THE'WOpK 1�ND THE S'CPUCTURE IS NOT INTEF�ED OR OFFERED FOR SALE(SEC.7044,B11S1- J ",'NE55 AND PROFESSIONS CODE:ITHE CONiRACTOHS UCEtVSE LAW DOES NOTAPPLY TO AN oWNER OF � � +�PHODERTVWHOBUIlASQRIMPROVES�,.THEREON,ANbWHODDESSUCHWORKHIPASELGOqHERSELFOR � Q�� ',��.7HflOUGHNISORHEROWNEMPLOVE�3,PROVI��T4ATSUCHIMPROVEMENT9pRENOTINTENDE00R � ' . ' � "' � ' � ;OFFEHED FORSALE IF,HOWEVER TME B111L61NG OH iMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE i�TION,THE OWIdER-BUfLDEfl WILli HAVE 7HE BURDEN OF PROVING THAT NE OR SHE DID NOT BUIID OR I I,IMPP.OYE FOR THE PUflPOSE OF�SALE)� . . . �� . ��, . ❑l.ASONMEROFTHEPHOPERTYhAA1EXCWSIVELYCANTRACTINGWITHLICENSEDCdN7RACTORS , . (t 'TO CONS7RUCT YHE PROJEC7{SEC.7044.BU31NE5S APiD PROFE9810N5 CODE:THE CONTRACTORS LI• �ly��gfip� �, � . . AD,J.AREA QLI ���.CENSEUWDOESN6TAPPLYTOIRNOWNEHOFkPflQPERTVWHOBU1LU50RIMPROYES7HEREON,AND � IiW�-pQpNTMCTSFOflSUCHPRQIECTSWITHACANTqA6TOR�5)LiCENREDFURSUANTTOTHECONTfiAC QUANTITY DESCRIPTION '� , FEE � � ;"'�70R5 tlCENSE LAIN.). - �/ �� ❑I Md EXEMPT UNDER SEC: 9.&P.C.FOR'tHIS REASON U �� ,�t' - �� � � � r . �'L" OATE OWNER �" � - � � W � � q LiCENSED CONTRACTtl�RS DECLARATION W '� ,� � �.���'� OC 1 HEHEBV APFIRG UNDEB PENALN OF PERJURY TNAT I AM LIGENSED UN�ER PqaVlSIONS oF CHAPTEfl � „ a, B(COMMENCIiFGW1TH5EC710N7aW)OFDIVISION3tlFTHEBUSINESSANDPROFE5510NSCODE,AND X. MY UGENSE IS!N FULL FaRCE AND EFFEG7. m r', ' b ' LL O LICEN5E C�UI,�SeS.�{ LIQ NO. . _ ~' DAlE �"'-'L�i�CONTFtAG70R �- v E �' � � w � WORKERS'COAAPENSATION DECLARATION ¢ ' ' � i H E AFFIRM UDIDER PENALT'OF PERRIRY ONE OFTHE FOLLOWItiu OECLARATIDNS: U a' y Z , L7 IHAVEANOWILLMAINTAINACER7�FICATEOFCONSENTTOSELF•INBUREFORWOPKERS' _ � `y�'�+.�, I � CAFlPENSATION,ASAROYIDEDBYSECilON37ooOFTHELABORCOOE,FOPTHEPERFORIAANCE C.� F THE WORK FOR WHICH THIS PERMiT IS ISSUED. � i A W 'IFIRVE/�lOWil1MAINTAIPIWDRKER5C04APEN5AT10NIN5URANCE,ASREOUTAEDBYS'cCTION F� ,(� f � 37WOF7HELA60RCODE,FORTHEPERFOFilA�VdCEOFTHEWORKFOpWHICHTHfSPERMlT15 j ��La� ISSUE�.MY WORKERS'mMPENSAT!ON INSURANCE CAFlRIER AND POLICY NUMBEfiPAE: CONSTRUCTION ��0�� e��� �wl �� � c.naai� � PLAN REVIEW � � pOLICYNUMBER �-1.���_ � � � ELECTRIC Q � !� �. Q (fHSSECiKKJHEEDNOTBEWMMET'cDOF'fFdE?EFV.YPISFORaJE4iUNDREDWLU�FlS(SICOJORLESS�. PLUMBING ���y , .,.y ry y. p rV' ' , , Z ICERTIFYTHATIN7�iEPEAFORMANCEQFTHEWORK�ORWHICHTHISPERMl71SISSUE�,1 McCHANICAL �1�1 13 a�� li f (S SHPL4 NOT EMPLOY AP1V PEflSON IN ANY MANNER�AS T6 BEG�ME SUBJECT TO THE , � C � WORKERS'COMPENSATIONLAWSOFCA�IFOHNIA,NVDAGREETHATIFISHOULOBECOME iNSPECTiONFEE � � : �: r �°1� ' � SU&IECTTOTHEWOPKEfiS'COMPENSAiIONPROVISION30FSECTION9]o00FTHELABOR j""�e�; ,j � ��a� �y � f.00E,I SNALL FORTHWI7H COMPLY WITH THOSE PROVISI6NS. �Ary ISSUANCE L i �/'� � DA7E:�� APPLlCANT:�i��P�/,• i .d /v-e�`�' �SMIP �`d`a��:`4�? f� ., � . R 4 1r � � � ENERGY P/C ' . 3'� �S � ��'�'� ' J WAflN!NG:FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFIIL,pN0 SHALL 8E q� .� � , 'i yj_ SUBJEGTANEMPLOYERTOCRIMINALP�NAlT1ESAKDCiVILFMESUPTOONEHUNDRWTHOUSAN� ENERGYPERMIT DOLI.ARS(S1CO,M0),IN ADDI710N TO THE COST OF COMPENSATION,DAMAGES AS PROYIDED FOR IN � J SECTION 37oe OF TIE LABOfl CODE,INTEftEST,ANO ATTORNEV'S FEES. ' . RETENTION FEE: � p�,. CONSTRUCTION LENDlNG AGENCY PRE-ALT FEE: O � �� IHEAEBYpFFIRMUNDERPENALTYOFpERJURYTHATTHEREISACqNSTRUCTIONLENDINGAGENCY FOR THE PERFORMANCE OFiHE WORK FOH WHICH THIS PEFMIT IS ISSUEO(SEC.309],CIV.C.). ' y m � �LENOER'SNAME��>�„����� � I— �ENDER'SADDAESS � w�. ���� �� ICERTIFYTMATIHAVEflEAOTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATIONISGORRECT. TOTAL FEES �. I AGREE TO CAM?LY WITH ALL CIN AN�'COUNTV OFDINANCES AND STATE LAWS RELATING TO BIJILDING e �. CONSTqUCTION,ANDHEREBYAUTHORi`LEREPRESENTA7IVESOFTHISCOUNTYTOBJTERUPONTHE I L ABOVE-MENTIONE�PROPERTYFORINSPECTIONPUflPO5E5. COMMENTS � Q, �:..fi��,l�-'6'' �'-C� m' PEflMIT7EE NAME(PPINT) ' c�i� .z.r-.r�.- �C3 � ' (�} SIGW4 E� PERMI k DAPE , 'I z � pECPTNO. 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