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HomeMy WebLinkAbout17222 ' � ---_�. . _._ CTTY OF DIAMOND BAR � DEPARTI��IENT OF COMMUNTTY&DEVELOPMENT SERVICES �� � _ � �� ' 21825 E.Copley Drive J (909)860-3195 Fax(909)861-311? /�•-� PR ESS ��v�Y� BUILIDING PERMIT APPLICATION � FIRMLY y JOBSITE /�(�� r(�GrY, 1•, � APPLICATION 1 O Q� NUMBER ����/C o ADDRESS 9 UY I 1'Ci DATE ( � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER r � ADD S Y� a" ZONING SETBACKS 0 Z CITY �' ZIP TEL. FRONT R�/y ❑p � APPLICANT TEL. REAR Z SIDElSIDE STREET RW ❑ a CONTRACTO L SIDE � ADDR S hc � CITY ZIP TEL. `1 PROPOSED USE oARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIFiM UNDER PENALtt OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gel'ege,�Cefport W CENSELAWFORTHEFOLLOWINGREASON(SEG7037SBUSINESSANDPROFESSIONSCODE:ANYCITYOFi (n U COUNTVWHICHREDUIRESAPERMITTOCONSTRUCLALTER.IMPROVE,DEMOLISH,ORREPAIR0.NVSTRUC- W P2II0/DOCk Z TURE,PRIOR TO RS ISSUANCE,ALSO REIX11RE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- W � CENSE lAW(CHAPTER B(COMMENqNG WITH SECTION 7o00)Of�I41510N 9 OF THE BUSMESS AND PRO- u' PooVSpa O FESSIONSCODE)ORTHATHEOf1SHEISEXEMPTTHEREFROMANDTHEOASISFORTHEALLEGEDE%EMP� (� V TION.ANVVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof A CIYIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS(ESoo7.): � ❑I,ASOWNEROFTHEPROPERT',ORMYEMPLOV�ESWITHWAGESA57HEIRSOLECOMPENSATION, � Commercial Z WILL�O THE WORK,AND THE STRUCTUFE�S NOT INTENOED OR OFFERED FOR SALE(SEC.7044,BUSI� J � NESS AND PROFESSIONS CO�E:THE CONTRAC70RS UCENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK H'�MSELF OR HERSELF OR � THROUGHHISORHEPOWNEMPLOVEES,GROVIDEOTHATStJCHIMPROVEMENTSARENOTINTENDEDOR m � OFFEREDFORSAIEIF,HOWEVER,THEBUIL�INGORIFAPROVEMENTIS50LDWITHINONEYEAROFCOMPLE� Z TION,THE OWNER�BUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORhiEPURPOSEOFSALE). W ❑I,ASONTlEROFTHEPROPERN,AMEXCLUSNEIVCONTRACTINGWITHLICENSE�CONTRACTOqS � TO CONSTRUCT THE PROJECT(SEC.7o4s,BUSINESS AN7 PROFESSIONS CODE:THE CONTRACTORS LI- V8IU8IIOf1 ADJ.AREA W CENSEUIWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AN� � WMOCANTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPUFSUANTTOTHECONTflAC- OUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). � ❑1 AM E%EMPT UNDER SEC. B.8 V.C.FORTHIS REASON � O V � � � DATE OWNER � Z W � UCENSED CONTRACTORS DECLARATION W ¢ � I HEREBY AFFIRM UNOER PENAITV OF PERJURV THFT I NM LICENSED UNDER PROVISIONS OF CHAPTER � A y/ d 9(COMMENCING WITH SECTION 7000)OF DNISION 3 0F THE BUSINESSAN�PROFESSIONS DE,AND Z 'V� X MY UCENSE IS IN FULL FORCE AND E FECT. � LICENSECLAS � LIC.NO. ��'�O � � J V DATE � GONTRAGTOR d �"' j��' �t`� �'--� WORKERS'COMPENSATION DECLARA Q � I HEREBV APFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z Z _IHAVEANOWILLMAINTAINACEFTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' a 2 4 COMPENSATION,AS PflOVIDED BY SECTION 370o OF THE LABOft CO�E,FOR THE PERFORMANCE W Q OF THE WOFK FOR WHICH 7HI5 PEflMIT IS ISSUED. � w �1 HAVE AN�WILI MAINTAIN WOPKERS'COMPENSATION INSURANCE,AS REOI.'IRED BY SECTION Q 3700 OF THE LABOR CODE,GOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.MY WO�/E�RS COMPENS TION PANCE C AND PO�y�/Y'�NUMBER ARE: CONSTRUCTION J CARqIER 1 4/��o nt 1 �'1�� W j PLAN REVIEW Z POUCY NUM6ER IA�_���I���I ELECTRIC Q 1 � (fHIS5ECT10NNE�NOTBECQNPLETE�OFhIEPEW.4TISFORONEHUt�RE�Oq1ARS(5100)ORLESS� PLUMBING 1� � Z ICERTIFVTHATINTHEPERFORMANCEO=THEWO KF R HICHTHISPERNITISISSUED,I MECHANICAL (.J' SHALLNOTEMPLOYhNYPERSONINANYMANNE O 5 BECOMESl18JECTTOTHE � WORKERS'COMPENSATIONLAWSOFCAIIFOR A EETHATIFISHOULDBECOME INSPEC710NFEE Sl16JECT T0 THE WORNERS'COMPENSATI I OF SECTIO�37a0 0F THE LABOR � � CODE. HAL FORTHWITHCOMPLYWIT IONS. ISSUANCE �� O p DAT �a O� A^�PPLICANT: SMIP _ J WARNING: AILUR TO�ECURE WOFKERS'COMP. OVEHAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C � SUBJECTANEMPLOVERTOCRIMINALPENALTIESAIV IVILFINESUPTOONEHUNDRE�THOUSAND ENERGVPERMIT DOLLARS(E700.000J,IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PHOYIDEO FOF IN ¢ SECTION 3708 OF THE LABOR CODE,IN7EREST,AND ATTORNEYS FEES. RETENTION FEE: d CONSTRUCT�ON LENDING AGENCY PRE-ALT FEE: O � 1 HEREBYAfFIPM UN�ER PENALTV OF PEFiJURV ThiAT THERE IS ACONSTRt1CTI0Y'�_ENDING AGENCY FOR TME PEflFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED�SEC.309�,CIY.C.). Z W � LENDER'S NAME F- LENDER'SADDRESS � TOTAL FEES � � :�� � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. w I AGREE TO COMPIY WITH ALL CITY AND CAUNTY ORD�NANGES AND 5T0.TE LAWS RELATING TO BUIL0ING � WNSTRUCTION,ANONEREBVRUTHOR12EPEPflcSENTATIVESOF'HISCOUNTVTOENTERUPUNTHE � ABOVE�MENTIONED PROGEFTY FOR INSPECTION PUFPOSES. z COMMENTS O J � m PERMITTEE NAME(PflIN � D �O1 � SIGNATURE OF PER EE �A E = RECPT.N0. 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