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Home My WebLink About15155 (17)Crff OF DIAMOND BAR DEPARTMENT OF.COMMUNITY & DEVELOPMENT SERVICES 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICA rinmor APPUCAMW- ESS --V,05114WQr APN1f$#,2— -0--f3-iTRACT :ffw Num OWNER —ZQ1 ADD J UI CITY APPLICANT T --&dA&Z CONTRACTOR ADDRESS ZONING SETBACKS CITY ZIP TEL ARCH/ENG/ FRONT DESIGNER ADDRESS CITY ZIP TEL REAR 11 OWNER -BUILDER DECLARATION SIDE/SIDE STREET IHEREBY AFIFIRM UNDER PEN&TY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U ❑0 CENSE LAW FORTHIEFOU.0WING REASCIN (SED. 70311 BUSINESS AM PROFESSIONS COOLANY CITYOR COUNTY WHICH REQUIRESAPERIMITTO CONSTRUCT ALTER. IMPROVE. DEMOUSK OR REA04RANY STRL)C- SIDE TUAL PRIOR TOITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO PASA SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U ---,Gas (OOMMGNC1MQVdTHS6CnON?000)OFDMSION3 OF THE SUSINESSAND PRO. Z:i AAT C-0 FIESSIONS OODE)CATHATHE OR SHE 0 EXEMPTTHEWROM NO THE BASIS FORTHEALLEGED E)MMPw TwKAmyvKxmmmoFsEcTioN=iAuyAmyAppurANT AoRAPEmw SUBJECTS THEAPPLrAwro ACIVAL PRiALTY OF NOTMOAE THAN FIVE HLINORFDDCILLARS 050)),l: 13 LABOWNEROFTHE PROPERTY, OR MYEMPLOYEESWITHWAGESAS THEIR $OLE COK943MTMK WILL 00 THE WORM, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SME (SEG 79K bUSI- NESS AND PROFESSIONS COOS: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF -4fKWAWMHDWLDSIDR&VW"JESTHEREDKANDWH000EBW"NINIEFUS6 ,DR HEA&RFOR BEDROOMS THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFRMMFORL4LEF.NDWMKTHEBULDMORLIPROVEMBIrSSMDWTnMONEYEAROFCDLVLE- FACTOR PSIF TOOK THE THE BURDEN OF PROVING THAT HE OR SHE DID N" BOLO OR, OVINHE WF IMORMFORT-R=0 S= SFRADDAEMI a LAS OVINEROFTHE PROPERIXAM EXCLUSIVMYCONITRAGRNG MY14 LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SM 704A BUSINESS AND PROFESSIONS OODE-- THE CONTRACTORS U CENSE LAW DOES NOTAPPLY 110 AN OWNER OFAPROPEM WHO BULDS OR IMPROM THEREON. NO ca WHOOONTRACT51FORSUCHIPROJECTSIVITHA PUFAUMNTTOTHECQNTRAr- TOM LICENSE LAMI.), I . JIAMEXEMFTUNDERSEG IL & F.Q FOR THIS Ft EASON MiE ILL poovsm LICENSED CONTRACTORS DECLARATION. I HEREBYAFFAM UNDER PENALTY OF PERJURYTHAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 3 OF THE BUSINESS AND PROFESSIONS COOL AND Lwsmse aAss LIC. NO DATE OONTRACTOR YYORILffiS' COMPENSATION DECLARATION I HERESY AFFIRM UNDER PENALTY OFPELIUAY ONE OF THE FOLLOWING DECLARATION& COMITMCIIII ACEKrfflrATEOFCOMENTTOSELF4NSUFUE FOR WORKERS LC _IHAVEANDWILLMAINTAIN COMPENIIATICKAS PROVIDED BY SECTION 3700 OF THE LABOR CODE. PORTHEPERPDRMANCE -5 OFTHE WORK FOR WHICH THIS PERMIT 0 HAVE AND WILLMAKTAIN WORKERS' COMPENSATION INSURANCE AS REQUIRED BY SECTION 3700 OF THELABOR CODE" FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUE[IL MY INORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICYNUMBER Valuation #IV MOSETIONNEIZ)NCIrKMWWMOFr*EPEFUTEFOR04EHJCRSDMUAF41CM"ORLM LLJ z - I CERTIFY THAT LATHE PERFORMANCE OF THE WON FOR WHICH THIS PERMIT 18 ISSUED, I E2 SHALL NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SU[UrCT TO THE INORKERS COMPENSATION LAWS OF CALNKNVOA AND AGREE THAT IF I SHOULD BECOME SUajEcT TO THE V"KERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CQDE. I OWL FORTHWITH COMPLY WITH THOSE PROVISONSL 0 p DATE APPLICANT. FAILURE TO SECURE WOWERS' COMPENSATION COVERAGE IS UMLAWPUL AND SHALL BE %"CT AN EMPLOYER TO ORIMNAI, PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS C9109,010). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3702OFTHEUBM CODE INTERESTANDATTORNEVS FEE& AJC CONSTRUCTION LENDING AGENCY O U.1 I HEREBYAFFIRM WIDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ((EC. SM. CIV. CL). 63 LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I HAVE AM THIS APPLICATION AND STATE THAT THE ABOVE DFORMATION IS CORRECT. O. I AGREE TO COMPLY WITH ALL CITY AND COMM ORDINANCES AND STATE LAWS RELATM TO BUILDING Z CONSTRUCTION. AND HEREINREPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE A80VE4AENTION P1E PURPOSE& o E PF, ONE n. wm I c--w4waninent vwy, T Q1iV— % W, 0 PRESS ----- it A U11% rinmor APPUCAMW- PE RM 0 1C DATE rE I :ffw Num I ISSUE TYPE ow ATE DATE4 GROUP ZONING SETBACKS FRONT RW 0 REAR 11 SIDE/SIDE STREET RW ❑0 SIDE PROPOSED USE Z:i AAT C-0 NO. DWEL NO. No. UNITS' STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSIF ADJ. AREAIVALUATION SFRADDAEMI ca LLJ LLI ILL poovsm R94W-- - COMITMCIIII -5 Valuation #IV ADJAREA QUANTITY DESCRIPTION FEE' ij U.1 LU Z n. CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE zw SMIP AN 2 3' 2000 ENERGY PIC ENERGY I PERL41T CITY OF DIAMOND ]BAR RETEwnoNrEE:*.-. BUILDING AND -SA TY ME -ALT FEE -- TOTAL FEES COMMENTS T REcp-r. No. 'I Lf' I -/— PAID BY I , ?J t ) - VALIDATION