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HomeMy WebLinkAbout17317 (26) CITY OF DIAMOND BAR ----�`' -- DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES �_ �,� � ' 21825 E.Copley Drive (909)8603195 Fax(909)861-3117 PRESS "''%v�M` BUILDING PERMIT APPLICATION FIR Y � JOBSITE �d�rs ��E�✓� �a APPLICATION �1�-`,�� � NUMBER I� , P/C o ADDRESS_D��L� F�o<- DATE # o� ISSUE TYPE OCC APN LO�__ TRACT DATE � � � CONS7. GROUP p OWNER !V " ADDRESS TLE 1� ZONING SETBACKS Z CITY ZIP TEL. '( 9 FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIDEJSIDE STREET RW ❑ z Q CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE � M� N �N � CITY ZIP TEL. o ARCH/ENG/ iz DESIGNER NO.DWEL. NO. NO. a ADDRESS LINITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFiL'ADDlREM O p I HEREBV AFFlFAI UNDER PENAITV OF PEPJURV THAT I AM E%EMFT FHOM 7HE CONTRACTORS LI� Gdf89B/C8fp0ll W CENSELAWFORTHEFOLLOWWGREASON(SECJo31.5BU51NE55ANDPRpFE5510NSCODE:ANYCITYOR (n U COUNTVWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTPUC- W P&ti0/DBCk Z 7URE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICAN7 FOR SUCM PERMIT TO FILE A SIGNED W W STA7EMENT THAT HE OR SHE IS IICENSEO PURSUANT TO THE PFOV'SIONS OF THE CANTRACTORS LI- � CENSE LAW(GHAPTEF 9(COMMENCING WITH SECTION 7000)OF pIY1510N 3 OF THE BUSINE55 AND PRO- �'1" PooVSpa FESSIONSCO�E)ORTHATHEORSHEISEXEMP7THER'cFROMANDTHEBASISFOqTHEALIEGEDEXEMP- � � TION.ANYVIOLATIqJOFSECTION7C31.58YANYAPPLICAN7FOPAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Rooi � ACIVILPENALiVOFNOTMORETHANFNEHUNDREDDOLLARS(S5oo).): Q ❑I.ASOWNEROFTHEPROPERTV.ORMYEMPLOYEESWITHWAGESFSTHEIRSOLECOMPENSATION, � COflll118fCi2I Z WILL DO THE WORK,AND THE STRUCiURE IS NOT�NTEN�ED OR OFFERED FOR SALE�SEC.7044,BUSI- J NE55 ANO PflOFE5510N5 CO�E:THE CONTflACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPER7YWIiOBUILO50RIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m � TH(iOUGHHISORHEROWNEMPLOYEES,PROVIDEOTHATSUCNIMPROVEMENTSARENOTWTENDEDOR QOFFEREDFORSALE.IF,HOWEVEF1,hIEBUIL0INCORIMPFYOVEMEN7155OLDWITiINONEVEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PPOVING TI1A7 HE OR SHE DI�NOT BUILO OR � IMPROVEFORTHEPVRPOSEOFSALE). ❑1.AS OWNER OF THE PR�PERTY,AM EXCLUSIVELY CONTRACTING WI1H UCENSED CONTRACTORS � TO CONSTRUCTTHE PRQJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONiRACTOFS LI- V8II1a110f1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPflOPERTVWHOBUILDSORIMPROVESTHEREON,ANC1 � WHOCONTRACTSFORSUCHPROJEC'SWITHACONTRACTOR(S)UCENSEDPURSUANTTOTHECOMRAC- QUANTITY DESCRIPTION FEE Y TORSUCENSEIAW.). � J � ❑i AM E%EMPT UNDER SEC._ B.8 P.C.FOR TMIS REASON � � �O� OWNER � DATE V Z W �c[ LICENSED CONTPACTORS DECLARATION W CC 1 HEREBY AFFIRM UNOER PENALTV OF PERJURY THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTEF � � 9�COMMENdNGW17HSECTION700o)OFDIVISION30FTNEBUSINESSANDPROFESSIONSGO�E,ANO Z �X MY LICENSE IS IN FULL FORCE AN�EFFECT. m � LICENSE CLASS LIC.NO. J U �ATE COMRACTOR d W � WORKERS'COMPENSATION DECLARATION Q � V � IHEREBYAFFIRMUNOERPENALTYOFFERJURYONEOF7HEFOLLOWINGDECLARATIONS: � Z 4 � _IHAVEAN�WILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWOPKEFS' 2 Z GOMPENSATION.AS PROVIDED BY SECTION 3too OF THE LABOR CODE,FOR THE PE�FORMAMCE U ¢ OFTHEWORKFORI4HICHTHISPERMITISISSUEO. � � w _I NAVE AND W'.LL MAINTA'N WOFKERS'COMPENSATION INSURANCE,AS FEO�IRED BV SECTION - Q 37aoOFTHELA80RCODE,FORTHEPERFORMANCEOFTNEWORKFORWHICHTHISPEFMITIS ISSVE�J.MYWORKERS'COMPENSATIONINSURANGcCARRIERANDFCLICYNUMBERARE: CONSTRUCTION J j CAftRIER PLAN REVIEW y� � POLICVNUMBER ELECTRIC '4� `-� ¢ Q (iFII55ECTIONNEmNOTBECOMREfEDOFTHEPERMRISFCRONEHUNDfiEDDJIlAAS(E1001�RLESSj. PLUMBING Z ICERTIFVTHATINiHE7ERFOfiMANCEOFTHEWORKFORWHICHTNISPERMITi51S5U=0.i MECHANICAL Lj SHAIL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE� � WORKERS'COMPE�S0.TION LAWS OF CA4IFORNIA.AN�AG4EE THA7 1F I SHOULO BECOME INSPECTION FEE = SUBJECTTOTHEWORKEflS'COMPENSATIONPROVISIOVSOFSECTION37000FTHELABOR CODE,I SHALL FORTHV✓ITH COMP'_V WITHTHOSE PROVISIONS. ISSUANCE � � SMIP p DA7E: APPLICANT: W ENERGY P/C —� WAPNING:FAILURE TO SECURE W�RKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESAN�CN�LFINESl1PTOONEHUNDRE�THOl1SAN[1 ENERGYPERMIT DOLLARS(5100.Doo),IN ADDIl10N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION37080FTHELABOFiCO�E.INTEREST,ANDATTOPNEV5FEE5. RETENTIONFEE: � _--_ � CONSTRUCTION LENDING AGENCY PRE-AL7 FEE: O � IHEFEBYAFFIRMUNDERPENALTYOFPEflJURY7HATTHERE'.SACONSTRUCT�ONLENDWGAGENCY � FORTHE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSLlFO(SEC.3097.CIV.C.�. —�- Z I W ? LENDER'SNAME � H LEN�ER'SADDRESS^ � ICEPTIFY7HATIHAVEREADTHISAPPLICATIONA`7DSTATETHATTHEABOVEINFOflMATIONISCORRECT. TOTAL FEES w I AGREE TO CO�iPLY WITH AL'�CINAND COUNTV ORDINANCESAND STATE LAWS RELATING TO BUI�OING � CONSTRl1CTiON,ANOHEREBVAUTHORIZEREPFESENTATiVE50FTHISCOUNTYTOENTEFUPONTHE � ABOV�I.",/-Y D PP�PFGTY FOR INSPECTION PURPOSES. COMMENTS / 0 � m P E T) � L�'�'� N 51 l: ERMITfEE DATE _ - RECPT.NO. PAID BY VALIDATION ~ WHITE—Departrnent Copy,VEILOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy.GREEN—ApplicanYs Copy . ... . . y,�" i �a� :;� ..r �i�',�. .:..�d..,.'n .,}i�'�. . _ -:'S" ,..e.,N�L , .,'",�.% u,�'.�' .. �,.. . u. ,. s<.-:.,.�-..� : :: ,m� �-xv'M'��Sro"�`�'T.,Y, . '. . .,..� )'. . f. �?q"j.�w:.:.�t.�,.. ..,..� ..�.,,,:," ...�..j:,w.. . . ._. . . .....,. ... . ., _�. '��� . �w�` �"�p���ga�m7�a�,� ��^,���'� � � a;:;r r �.,��:e�.� �:_�� �.ffi�=r�",.�-`.,:� � .� '.:::�.� ��� � �'�,� � :.�����.Z��� a �; � ��� � ��'` �. �-,b�� � a���a ��. 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