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HomeMy WebLinkAbout17486 (26) - - � CITY OF DIAMOND BAR �" G.� � �'�`-- DEPAR'd1viENN'I'OF COMMUNITY&DEVELOPMENT SERVICE5 � I � 21825 E.Copley Drive (909)8603195 Fax{909)861-3117 PRESS ' '%•�A��' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE APPLICATION �����PERMIT � /C o ADDRESS t���a} �L,L+�''�'j2., E'',I'��..^'� L,.�l� DATE NUMBER CJ f �� � ISSUE NPE OCC APN LOT "7� TRACT .i���� DATE CONSt ._ GROUP p OWNER C).�ifaP".L.e�S 3Ia ���`1°�G�G.� ADDRESS ��+�s�-Li�%�/f_ �L�if !°_sS.N��' ZONWG SETBACKS Z CITY�J3k'i'P��9�i�'i9-�2 ZIP��TEL. ��"��� FRONT RW ❑ � APPLICANT F'�zt�is TEL. REAR � � SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR SIDE � ADDRESS � CITY ZIP TEL. PROPOSED USE f � o ARCH/ENG/ �' DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM IJNDER PENALTY OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS L!. � Garage/Carport W CENSELAWFORTHEFOLLOWINGHEASON(SEC.7o91.5BU51NE5SANOPROFES510NSCODE:ANVCITYOR C�. COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCi,PLTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W PatidDeck � Z. TUHE,PRIOR i0 ITS ISSUANCE.PL50 fiE�UIFES THE NPPLICANi FOfl SUCH PERMIT i0 FILE A SIGNED w �� SiATEMENT THAT HE OR SHE IS I;ICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- g, CENSE LAW(CHAPiER 9(COMMENCING WITH SECTION 7006)OF DIVISION 30F THE BIJSINE55ANO PF0- � POOVSPB � FESSIONSCODE)OFTHATHEORSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXEMP- (� . V TION.ANVVIOLATIONOFSECTION7031.5BYANVAPPLICANTFORAPERMITSU9JECTSTHEAPPIICANiiO z Re-Root ACIVIL PENALTY OF N07 MOqE TNAN FNE HUNDRE�DOLLARS(55oo)J: 0 ❑I,A$OWNEROFTHEPPOPEFN,ORMVEMPLOYEESWITHSNAGESASTHEIRSOLECOMPENSATION, ❑ COfflfllefCiBl ' Z 'WILL 0a THE WDRK,ANU iHE STAUC7l1RE IS NOT INTEN�E�Ofl OFFEREO FOR SALE(SEC.7044,BU51- J NESS 0.ND PROFESSIONS CO�E:THE CONTRACTORS LICENSE LAW 00[S NOT APPLY TO AN OWNEfl OF � PROPERNWHOBUILOSORIMPROVESTHEREON,AN�WHODOESSUCHWORKHIMSELFORHERSELFOR � �[' '�.THROUGHHISORHEROWNEMPLOYEES,PROV;OEDTHATSUGHIMPROVEMENTSARENOTIMENDEDOR m Q �.OFFERWFORSALE.IFHOWEVER,THEBUILDWGORIMPROVEMENTISSOLOWIiHiNONEYEAROFCOMPLE- Z TION,THE OWNEF-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE�I�NOT BUIL�Ofl �� ��IMPPOVEFORTHEPUFPOSEOFSALE�. w ❑I.ASOWNEROFTHEPROP�RTT,AMEXCLUSNEIYCONTRACTINGW17HLiCENSEDCONTRACTOFS � ' i0 CONSTRUCT iHE PROJECT(SEC.7044,BUSINE55 AND PROFESSIONS CADE:THE CONTpACTORS LI- VOIfIdtiO� ADJ.AREA W, CENSELAW�OESNO7APPLVTOANONMEROFAPROPEFTVWHOBUIL�SORIMPflOVESTHEflEON,AND ��. . WHOCONTRACTSFOHSUCHPftOJECTSWITHACONiRACTOR(S)LICENSEDPUPSUANTTOTHECDNTRAG QUA.NTITY DESCRIPTION FEE Y .TORS LICENSE LAW.�. � ❑I AM EXEMPT UNDER SEC. 5 B.&P.C.FOR THIS REASON � U � � � � DATE `3 OWNER �" Z W a� LICEN5ED CONTRACTORS DECLARATION �j � I HERE9Y AFFIFM UNOER PENALTY���OF PERJURY THAT i AM LICENSED UN�ER PFOVISIONS OF GHAPTER � � � . � 9(COMMENqNGWITHSECTION7o00�OFDIVISION30FTHEBUSINESSANDPROFESSIONSCDDE,AND Z �X MY LICENSE IS IN FULL FORCE AND EFFECI ,� m � .LICENSE CLASS � LIC.NO.__ _ .,_ � J V DATE _GONTRAG70R 0- W � WORKERS'COMPENSATION DECLARATION Q � V ....,, �"OfPERJURYONEDFTH:FOLLOWIYG�ECLARATIONS; z . ........... .C.I� . 14EREBYAFFlRM UNDE PENAL Q ZIHAVEANOWILLMAINiAIN'FCERYIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ �COMPENSATION.AS PROVIDED BVSECTION 3�oa OF THE LABOR CODE,FOR THE PERFOAMANCE U Q OFTHEWORKFORWHICH;THISPERMITISISSUED. � � � _IHAVEANDWILLMAINTAIN�iWORKERS'GOMPENSAiIONINSURANCE,ASflEQUIREDBYSECTION QQ. 3700 OF THE LA80R CO�E;FOq THE PERFOFMANCE OF THE WORK FOfl WHICH iHiS PERMIT IS ISSUED.MY WORKEAS'C0�,4�ENSATION INSURANCE CARRIEflAN�POLICVNl1M8ERARE CONSTRUCTION Q � CARRIEP PLAN REVIEW Z POLICY NUMBER ELECTRIC �� Q .,,,..�o' , � (I}iI55EC710NNEmNOTBEOJMPLtTE�OFTHEPERM(�ISFORONEHU�REDDOLLARS�$140)ORlESS�. PLUMBING ZICERTIFVTHATINTHEPERFORMANCEOFTHEMlORKFOflWHICHTHIS�ERMIiISISSUED,I MECHANICAL ('3' SHALLNDT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTOTHE . ,� y WORKERS'COMPENSATIONLAWSOFCALiFORNIA,ANOAGREETHATIFISHOl1LDeECOME 1NSPECTtONFEE F Sl18JECTTOTHEWORKER$'COMPENSATIONPROVISIONSOFSECTION3]OOOFTHELABOR � CODE,ISHALLFOPTHWITH:COMPLYWITHTHOSEPROVISIONS. ISSUANCE � SMIP �� p ' DATE: APPLICANT. W ENERGY P/C � . � . WARNING:FAILURE TO SECURE WdRNERS'GOMPENSA710N COVERAGE IS 11NLAWFl1L,AN�SHALLBE � � SUfiJECTANEMPLOYERTOGRIMINALPENALTIESANDGNILFINESUPTODNEHUNDREOTHOUSANO ENERGYPERMIT �� OOLL4RS(Etoo,Oao),IN A�DITIONTQTHE;COSTOF COMPENSATION,DAMAGES AS PROVIOE�FOF IN � SECTION3708DFTHELABOHCO�7,INTEREST,ANOATTORNEY'SFEES. RETENTIONFEE: ���. �. CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: O 4. �', IHEREBYAFFIpMUNOERPENALTYbFPERJURYTHATTHEREISACONSTfiUCTIONLENDMGAGENCY � . FORTHEPERFORMANCEOFTH6V�ORNFORWHiCHTHiSPERMITISI55l1ED(SEG309],CIV.C.). lil _ _ — � ' LENDER'SNAME 1'- LEN�ER'SA�DRE55 � TQTAL FEES � � ICERTIFVTHAiIHAVEREAOTHISq'PPUCATIONANDSTATETHASTHEABOVEINFORMATIONISCORRECT. � � , IAGREETDCOMPLYWI7HALLCIiYIANOCOUNTYORDINANCESANDSTATEL4WSRELATINGTOBUILDWG ��. CONSTRUCTION.ANDHEREBYAUTHOFIZEREPRESENTATNESOfTHISCOUNTVTOENiERUPONTHE Z ' AeOVE�MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMEN7S - 0 � _ �C�3�L� �f�t�i`��'!� m� 0 ]�66�NA�PRINT) CIJ y� � Uj, � SIG T RE ITTEE � '�. DATE � _� RECPT.NO. 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