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HomeMy WebLinkAbout17273 (10) CITY OP DIAMOND BAR /1"/ ^ - �'�` --1 DEPAR'TMENT OF CO1��vIUNTI'Y&DEVELOPMENT SERVICES ��� I 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRE$$ �%vr^� BUILDINGPERMITAPPLICATION FIRMLY y�, JOBSITE APPLICATION f � PERMIT ��] P/C o ADDRESS_1 1� �rn DATE I� L � NUMBER" f�� # � ISSUE / TYPE � OCC APN LOT TRACT DATE l� "1 � CONST. GROUP p OWNER Cimarr�n nakS I H�A p ADDRESS (7�W �pqt�l�].-], �j�Vd #1.�(y ZONING SETBACKS z CITY('l�r�}�}q�}� ZIP Q1 71 1 TEL.�QC)-���,� FRONT R�/y ❑ � APPLICANT TEL. � REAR ❑ Z SIDE/SIDE STREET RW ❑ Q CONTRACTOR_ _Rn�al Rnnf r1� SIDE ❑ ADDRESS 4� � ���6p �� �� �f�.wond �hakes. Instal� o CITYPe�e�� ZIP Q1�7h�7� TEI.��}4�19_ PROPOSEDUSE P r w ARCH/ENG/ ' �z DESIGNER 7692 NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES tW0 BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADD/REM O p I HEREBY AFFIqM UNDEq PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI� GBfdCJB/CBfpOff W CENSELAWFORTHEFOILOWINGREASON(SEC.7o31.56USINESSAN�PROFESS10N5CO�E:ANYqTYOR (n CJ COUNTYWHICHREOl11RESAPERMITTOCONSTRUCT,A�TER,IMPROVE,DEMOLISH.ORREPAIRANYSTRIK� W PatiOlDBCk w TURE,PRIOR TO ITS ISSUANCE.ALSO RECUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNEO W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE LAW�CHAPTER 9(COIAMENCING WITH SECTiON 7000)OFD'�VISqN 3 OF THE BUSINESSAND PRO� � POOUSPfl Q FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP� � U TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPEFMITSU6JECTSTHEAPPUCANTTO Z Re-Roof ACIVIL PENALTY OF NOT MORETHAN FIVE HUN�RE�DOLLAAS(5500�.): � �I,ASONAJEROFTHEPROPEFTY,ORMYEMPLOYEESWITHWAGESASTHcIRSOIECOMPENSATION, � COrtIfIIBfCi81 Z WILI DO THE WORN,AND THE STRUCNRE IS NOT INTEN�ED OR OFFEREJ FOR SALE�SEC,7044,BU51- J � NESSAND PROFESSIONS CODE:THE CON7RACTORS LICENSE LAW DOES NOTAPPLY 70 AN OWNER OP � PROPER7V WHO BUILDS OR IMPROVES THEREON,AN7 WHO DOES SUCH WORK HIMSELF OR HERSELF OR � THROUGH HIS ORHER OWN EMPLOVEES,PROVIDED THATSUCH IMPROVEMENTSARE NOT INTENDED oR m w OFfEREDWRSALE.IF.HOWEVER,h1E8UILDINGORIMPROVEMENTIS50LDWITHIIJONEVF.AROFCOMPLE- � TION,THE OWNER-91111DER WILL HAVE THE BUPDEN OF PROVING THAT HE OF SHE DID NOT BUILD OP Z IAAPROVEf-0RTHEPURPOSEOFSALE). _ ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELVCONTRACTINGWITHLICENSEOCONTRACTORS W � TO CANSTRUCT THE PROJECT(SEC.7044,BUSINES^u AND PfiOFESSIONS CODE:7HE CONTRACTORS'_I� VBIIlHtI0f1 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPEPYYWHOBUILDSOR�MPROVESTNEREON,qND ' � WHOCOMRACTSFORSUCHPROJECTSWIiHACONTRACTOR(SjLiCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.�. 0 ❑I AM EXEMPT UNDER SEC. B.&P.4 FOR THIS REASON Q � U LL � DATE OWNER F— Z W � LICENSED CONTRACTORS DECLARATION W ¢ ' Q I HEFEBYAFFIRM UNDE(i PENALTY OF PEFJUPY THAT IAM L.ICENSED UNDER PflOVI510N5 OF CHAPTER � � e(COMMENCINGWITHSECTION7a0o)OFDIVISION30FTHEBVSINESSANDPFOFESSIONSCO�E,AND Z �X MY LICENSE IS M FULL FORCE AN�EFFECT. m � LICENSECLASS�—`�Q ,�I,� LIC.NO. [��'���� � U DATE�—�_1_�1r_ CONTRACTOP P��F�I�����_ 0. W � WORKERS'COMPENSATION DECLARATION Q NI HEREBYAFFIRM UNDER PENALTYOF PERJURY ONE OFTHE FOLIOWING DECLARATIONS: Z Z _IHAVEANDWILLMAINTAINACER7IFICATEOFCONSENTTOSELF�INSUREFORWORKERS' ,_ ¢ COMPENSATION,ASPfiOVIDEDBYSECTION3]UOOFTHELABORCODEF09THEPERFORMANCE C.� Q OF TME WORK FOR WHICH THIS PEaMIT IS'.SSUED. � � ��I HAVEAND WILL AAAINTAIN WORIfERS'COMPENSA710N INSURANCE,AS REQUIRED BY SECTION �/ Q 37000FTHE�ABORCOOE.FOfiTHEPERFORMANCEOFTFEWORKFORWH�CHTHISPERM1T15 � 9 a�6��. ISSUED.MV WORKERS'CAMPENSATION INSl1RANCE CARRIER AND POUCV Nl1MBER ARE: CONSTRUCTION � [(,)' � CARFIER Superior National PLAN REVIEW Z POLICVNUMBER Gi('AT—S2F,F,1 Q—� ELECTRIC ¢ � (hiISSEC'IONNE�NOTBE�OMPLEfEDOFTNEPERMRISfORQUEHUI�REGDJIJ.ARS(5100)ORLESS). PLUMBING ___ Z I CERiIF1'THAT W THE PERFORMANCE OF THE WORN FOR WHICH TNIS PERMIT IS ISSUEO,I MECHANICAL � SHALLNOTEMPLOYANYPEFSONINANVMMlNERSOASTOBECONESUBJECT70THE Uj WORKERS'COMPENSATIONLAWSOFCAL�FORNIA,ANOAGREETHATIFISHOUIOBECOME INSPECTIONFEE � SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370oOF THE LABOR � GOOE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE _ � O �.�p �ATE: APPLICAM: SMIP � ,_�j WARNING FAILURETO SECURE WOHKERS'COMPENSATION COVERAGE IS VNLP,WFUL,AN�SHAIL BE ENERGY P/C _._____ � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCNILFINESUPTOONEHUNDflEDTHOl15AND ENERGVPERMIT DOLLARS(f 100,000),IN ADDITION TO THE C�ST OF COMPENSATION,DAMAGES AS PROYI�ED FOR IN �' � SECTION3�oe OFTHE LABOR CODE,INTEREST,ANDATTORNEV'S FEES. flETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AF'rIRM UNDEfl PENALTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30B],CIV.C.�. Z W � LENDER'S NPME F— LENOER'SA�DRESS -y� WICEPTIFVTHATIFIAVEREADTHISAPPLICAiIONANDSTA'ETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � � �w �f A � I AGflEE TO COMGLV WRH AL'.CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILOING � � CONSTRUCTION,AN�HEREBYAUTHOPIZEREPPESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONEO PROPEflTY FOR INSPECTION PURPOSES. 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