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HomeMy WebLinkAbout17274 CITY OF DIAMOND BAR � � - ""ry,� - DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES � � _ �� 21825 E.Copley Drive (909)8603195 Faac(909)861-3117 PRESS %9�y�� BUILDING PERMIT APPLICATION FIRMLY y JOBSITE 1114 Cle horn APPLICATION (j PERMIT P!C o ADDRESS b' DATE �� �� � NUMBER��� # � ISSUE �e, � APN LOT TRACT DATE �� 7 C.� ONST. GROUP p OWNER im ron Oa G 1 HOA p ADDRESS �7� [,J �e��;7� R'I y�� ���/F ZONING SETBACKS FRONT (3W p o CITY(���re�e� ZIP���� TEL�{�(��,�_� REAR ❑ APPLICANT TEL. Z SIDE/SIDE STREET RW O Q CONTRACTOR Royal Roof Co. SIDE ❑ � ADDRESS (�.�� �r ��z�e ��� PROPOSEDUSE TPar nff wnnrl �hakPc Tnctall CITY ZI TEL��,�_ �w ARCH/ENG/e�� ��� Z DESIGNER �692 w — NO.DWEL. NO. NO. � ADDRESS UNITS STORIES _ BEDROOMS � CITY ZIP TEL. i.H�� � cn DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANA�UATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFF'�.RM UNDEP PENALTY OF PERJURV TMAT 1 AM EXEMPT FROM THE CONTPACTORS LI� Gdf8CJ6/C8lpOfi W CENSELAWFORTHEFOLLOWINGPEASON(SEC.7031.SBUSINESSANDPROFESSIONSCO�E:ANYCITYOR (n U COUMYWHICHRE�UIRESACERMITTOCONSTRUCT,A�TER,IMPROVE,DEMOLISH,ORAEPAIRANYSTRUC- Z TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIi1E5 THE APPLICANT FOR SUCH PERNIT TO fILE A SIGNEO W PatiolDeck w STATEMENT THAT HE OR SHE IS LICENSEO PUfiSUANT TO THE PROVISIONS OF THE CONTqAC70RS u� W � CENSE LAW(CHAPTEIi 9(COMMENCING WI7H SECTION 7000J OF D'VISION 3 OF THE BUSINESS AND 7R0� u' POOUSPB O FESSIONSCOOE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHE6ASISFORTHEALLEGEDEXFMP- (� U TION.ANVVIOLATIIXJOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof 3 O A CIVIL PENALTY OF NOT MORE THAN FIVE HUNORE�DOLLARS(5500�.)�. z ❑I,ASOWNEROFTHEPFOPEPtt,ORMVEMPLOVEESWITHWAGE5A5THEIRSOLECOMPENSAT�ON, 0 COrtlfnBfCidl WILL DO THE WORN,AN�THE STRt1CTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC,7040,BUSI- J � NESSAND PROFESSIONS CODE:THE CANTRACTORS IICENSE LAW DOES NOTAPPL'f TO AN OWNER OF � PROPEfiTY WHO BUILDS OR IMPROVES THEREON,AND NMO DOES SUCH WORK HIMSELF OR HERSELF OR Q THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMEN7SRRENOTIN7EN�EDOR m � OFFEREOFORSALEIFHOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE� Z TION,THE OWNER-BIIILDeR WILL HAVE THE BUPDEN OF PROVING TIiAT HE OR SHE DIO NOT BUIL�OR � IAAPROVEFORTHEPURPOSEOFSALE). w ❑I,ASOWNEROFTHEPROPERTV.AME%CLUSIV0.VCONTRAC7INGWITHLICENSEOCONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.7004,BUSMESS AND PROFESSIONS CODE:TFIE CONTRACTORS.I� VdIU3IlOf7 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOVJNEROFAPROPERiYWHOBUILDSOR'"MPROYESTHEHEON,AND - -- � WHOCONTRACTSFORSUCHPROJECTSWIiHACONTRACTOR(5)LICENSEDPUPSUANTTOTHECONTflAG QUANTITY DESCRIPTION FEE � TORS LIGENSE LAW.�. � ❑I AM EXEMPT UNDER SEC. 8.8 P.4 FOR 7HIS REASON Q � U ti � DATE OWNEF � Z � LICENSED CONTRACTORS DECLARATION W ¢ � IHEREBYAFFIRMUNOERPENALTYOFPERJURYTHATIAMLICENSEDVN�EflPROVISION50FCHAPTcR � d 9(COMMENCINGWITHSECTION70o0�OFDIVI510N30FTHEBU51NE55ANDPROFES510N5GODE,AND Z �X MY LICENSE IS IN FULL FORCE AND EFFECT. m � UCENSECLASS�—�� ,�C� LIC.NO.�1�p.f+7 � � J V DATE_J,jT�j CONTRACTOR d W • � WORKERS'COMPENSATION DECLARATION Q NI HEFEBYAFFIRM UNDER PENALTYOF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: Z Z _I HAVEAND WILL MAINTAIN ACER7IFICATE OF CONSENTTO SELF�INSURE FOR WORKERS' a _ ¢ �MPENSA710N,ASPROVIDEDBYSECTION3'lOOOFTHELABORCODEFORTHEPERFORMANCE U Q OFTHE WORK FOR WHICH THIS PERMIT IS'�SSUED. � � x��IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASFEOUIRE�BYSEC710N Q 370�OFTHELNHOPCODE,FOflTHEPEiiFORMANCEOFTHEVJORKFORWHICHTHISPERMITIS ��` �� ISSUED.MY WORKERS'COMPENSATION INSURANCE CARqIER AN�POLICV Nl1MBER ARE: CONSTRUCTION ¢ Superior National �, CARPILR (l7�7 GG A PLAN REVIEW � POIICYNUMBER Wb*Y�$FJd�QTlY ELECTRIC Z Q � (iHLSSEC'KKJNE�NOTBE�OMPLETEDOFTHEPERMITISFORP�EHUI�ARE��LLARS(St00�ORLESS). PLUMBING Z I CER7IFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,1 MECHANICAL C� SHALL NOT EMPLOY ANV PERSON IN ANV lJANNER SO AS TO BECONE SUBJECT 70 THE � WORKERS'COMPENSATIONIAWSOFCALIfORNIA,ANDAGREETNATIFISHOVLOBECOM[ INSPECTIONFEE � SUBJECTTO THE WORKEFS'COMPEN�ATION PROVISIONS OF SECTION 37ooOF THE LABOfi "^ GODE,I SHALI FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE � SMIP � /^s, p �ATE: APPLICANE f �,� J WARNING GNLURETO SECURE WORKERS'COMPENSATION COVERAGE IS VNLAWFUL,AND SHALLBE ENERGY P/C � SUBJECTAN EMPLOYEfl?O CRIMINAL PENALTIESAND CIVIL FINES UP TOONE HUNDREDTHOl15AND ENERGV PERMIT DOLLARS(51 oD,oa07,IN ADOITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIDED FOF IN � SECTION3708OFTHE LABOR CODE,INTEftEST,AND ATTORNEV'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBY AFFIRM UNDEfl PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LEN�ING AOENCY fOR THE FERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED jSEC.309],CIV.C.). Z W � LENDER'S NMAE 1-� LENDER'SAO�RESS � TOTAL FEES � . �% � I CEPTIFV TNAT I HAVE READ THIS APPLICATION AND STA'E THATTHE ABOVE INFORMATION IS CORRECT. L W I AGREE TO COMPLV WRH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUIL01�'G d � CANSTRUCTION,AN�HEREBYAUTHORIZEREPRESENTATNESOFTHISCOVNTYTOENTERUPONTHE Z ABOVE�MENiIONED PROFEFTY FOR INSPECTION PURPOSES. COMMENTS � J � m PEFMI E NA E INT) � Q / C!] `�"'1 ��(�� � SIGNATUFE OF P ITT E �ATE = RECPT.NO. � PAID BY VALIDATION ~ WHITE—Depadment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A licant's Co PY. PY� PY. 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