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HomeMy WebLinkAbout16680 (39) � �� CITY OF DIAMOND BAR � ----�--- I3EFA[tTIvfENT OF COI��IIv1UNITY&DE�IELOPMEN'I'SERVICES � I ,��� 21825 E.Gopley Drive (909)860-3195 Fax(909)861-3i17 PRESS '"<ti�y��� BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE APPLICATION - �m� t PERMIT /C o ADDRESS��'��''�.� ��:� I�etr. DA7E � NUMBER k o� ISSUE TYPE OCC APN � �OT�_ TRAGT�'���_� DATE CONST. GROUP p AD RE S�{�` C"lA..�,�,�� %�7.� Pt�" ZONING SETBACKS w ., r ,, �—• FRONT RW ❑ Z CITY r ^v A�Y✓a� ZfP�,�"TEL.��1���°�` , o APPLICANT TEL.��?-„��"�i�r"� REAR p Z �3 SIDEISIQE STREET RW ❑ Q CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE 'f "�t� `L� � °�� � CITY ZIP TEL. ;f i v2> o ARCH/ENG/ , f p . �, w DESIGNER NO.DWEL. NO. ` NO. a ADDRESS UNITS STORIES BEDR�OMS � CI7Y ZIP TEL. � � pESCRIPTION SQ.Ft FACTOR PSF ADJ.AREANALUATION m � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDEF PENALTV OF PERIURY THAT I AM EXEMPT FflOM THE CONiPACTORS LI- � Garage/Carport W �CENSELAWFORTHEFOLLOWINGf1EASON(SEC.7o31.5BUSINE55ANDPROFESSIONSCDDE:ANVCfTVOR . zCOUNTVWFIICHREOUIRESAPERMITTOCONSTRUCT,AITER,IMPROVE,DEAAOLISH,ORREPAtRANYSiRUC- W patiolDeck � �Tl1RE,PflIOR TO I75 ISSUANCE.ALSO REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED � � �STATEMENT iHAT HE OR SHE IS UCENSE�PURSUANT TO TH'c PFOVISIDNS OF THE CONTRACiORS LI- � '�CENSELAW�CHAPTER9(COMMENCINGWI7HSECTION�aoO)OFDIVISION30FTHEBUSINESSANDPqO- � PootlSpa �FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMAN�THcBASISFORTHEALLEGEDEXEMP- � �,TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFOflAPERM175UBJECTSTHEAPPLICANTiO Z Re-Roof � " � A CIVIL PENALN OF NOT MORE THAN FIVE HUNORED DOLLARS(E600J.): � � "�1 ASOWNEROFTHEPROPEflTV,ORMYEMPLOYEESWITH�YJAGESASTHEIR50LECOMPENSATiON, � Commercial - � Z �WILL G6 TNE WORK,AN�THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BUSI- J �. � �NE55 ANO PROFE5910N5 CODE:THE COIJTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF j . :�PROPERTYWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOq � Q �THROUGHHISORHEROWNEMPLOYEES,PROYI�EDTHATSUGHIMPqOVEMENTSAFiE�NOTWTENDEDOR m W� 'OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENiISSOL�WITHINONEYEApOFCOMPLE- � ��,TIDN,THE OWNER-BUIlOER WILL:HAVE THE BUR�EN OF PROVMG THAT HE OR SHE DID NOT BUILD OR Z 'IMPRWEFORTHEPURPOSEOFSALE)., _ ❑I.ASOWNEROFTHEPROPEFTY,AME%CLUSIVELYCONiRACTINOWITHLICENSEDCONTRACTOqS � ',,TO CONSTRUCT THE PROJECT(SEC.7oM14,BUSINE55 AND PROFESSIDNS CODE:THE CONTRACTORS tl- V21lJfitI0f1 ��� ADJ.AREA W �-CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUIL�SOR1MPqOVESTHEREON.ANo F '�WHOCONTRACTSFOflSUCHPRDJECTSWITHACONTRACTOR(S)UCENSEDPURSUAYTTOTHECONiRAC- QUAN717Y DESCRiPTION FEE Y !'TOR3 LICEN3E LAW.). �. , J � ❑1 AM EXEMPT UNDER SEC., B.8 P.C.FOR THIS flEA50N U ?s, . � � DATE�5�f.'�A OWNER J �� ��� ��r"�✓y✓ U ' W '��, � � UCENSED GONTRACTORS DECLARATION W 4 � � I HEflEBYAFFlRM UN�ER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � ��, B(COMMENCMGWI7MSECTION7oao)OF�IVISION30FTHEBUSMESSAN�PROFESSIONSGo�Je,ANO Z , W' 'MY LICENSE IS IN FULL FOflCE AND EFFECT. m � UCENSE CLASS LIC.NO. j U �DATE CONTRACTOR d W � WORKERS'COMPENSA710N DECLARATION Q � � - � I HEREBV AFFIRM UNDER PENALN OF PERJLIRY ONE OFTHE FOLLOWING�ECLARATIONS: ' Cl� Q � _IHAVEANDWILLMAINTAINACEqTIFICATEOFCONSENTTOSELF-INSUREFOflWORKERS' _ CAA.IPENSATION,ASPROVIDEDBVSECTION370DOFTHELABORCO�E,FORTHEPERFOflMANCE U ¢� OFTHEWORKFOFiWHICHTHISPERMITISiSSUE�. � 0 W `IHAVEAN�WILLMAINTAINWORKERS'COMPENSATIONINSURANCE.ASREQUIREDBVSECTION a ��„] Q 3700 0F iHE LABOR CODE,FOR THE PEqFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 � (/ ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUM6ERARE: CONST63UCTION J j CARRIER PLAN REVIEW _{ � z POLICYNUMBER EI.ECTRIC i 4 �� (MISSECTKNJNE�NOTBEOJMPLETEDOFTHEPERMfTISFORONEHUNOFlEDD011M1RS�57W)ORLESS). PLUM8ING � _ W i6� Z ICEfiTIFVTHA71N7HEPERFORMANCEOFTHENXIRKFOflWHICHTHISPERMRISi55l1ED,l MECHANICAL � SHALLNOTEMPLOYANVPERSO�JINANYMANNERSOAS?OBECOMESUBJECTTOTHE � WOFKERS'COMPENSATIONLAW$OFCAUFORNIA,ANDAGREETHATIFISFiOULDBECOML INSPECTIONFEE = SUBJECiTOTHEWORKERS'COhAPENSATIONPftOVISIONSOFSECTION3]OOOFTHELA60R � CODE,I SHALL FORTHWIiH COMPLV WITH THOSE PROVISIONS. �SSUANCE /' � SMIP � p �A7E: APPLICANT._, . � �� ENERGY P/C � J WARNINO:FAIIURETOSECUREWORKERS'COMPENSATIONCOVEAAGEISUNLAWFUL,ANDSHALLBE � SVBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUN�REDTHOUSAN� ENERGYPERMIT .DOLLARS(5100,oao�,IN ADtlITION TO THE'.COST OF COMPENSA710N,DAMAGES AS PROVIDED FOR IN J SECTION37080F'fHEL4BOFiCOOE,iNTEF=ST,ANDATTORNEY'SFEES. RETENTIONFEE: � d CONSTR(JCTION LENDING AGENCV PRE-ALT FEE: � IHEREBYAFFIqMUN�EqPENALTYOFPEaJIIRVTHATiHEREISpCONSTRUCTIONLENDWGAGENCY � FOR THE PEflFORMANCE OF THE WORK f-0R WHICH7HIS PERMITIS ISSUED�SEC.309],CIV.C.). � - Z W � LENOER'S NAME _ h— LENOER'SAOORESS W ICERTIFYTHATIHAVEflEADTHISAPPLICAiIDNANDSTATETHATTHEABO4EWFORMATION�s�oRRE�r. TOTAL FEES � � IAGPEETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESAN�STAiEL4WSRELATiNGTOBUILAING � CONSTRl1CTION,ANDHERE9YAlJTHOflREREFftESENTATIYESOFTHISCOUNTYTOENTEPUPOidiHE Z ABOVE-MENTIONED PROPERTY FOR INSt'ECTION PURPOSES. 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