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HomeMy WebLinkAbout15921 CITY OF DIAMOND BAR '''P��� �. ""-�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �.- � 21660 E.Copley Drive 3uite 190 �� ;; N (909)860-3195 F�(909)861-3117 �� PRESS ti ���'A�°. BUILDING PERMTl'APPLICATION FIRMLY A"- Q DDR�ESS '�l � I �� �,;��� APPLICATION 1 °�d= �{ � ERMIT �� P/C p �r�- ��" DATE � r�F��UMBER� # $ A ISSUE NPE OCC APN LOT ? T ACT DATE CONST. GROUP p OWNER �- � ! o ADDR� � ZONING SETBACKS Z CITY ZIP � �L. FRONT RW ❑ g APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ CONTFACTOR ' �{ - ` SIDE, n ADDR�S .!�' ' � CITY ' ZIP� C� TEL. � -- PROPOSED USE. ' `��r .�C,� ' w ARCH/ENGJ � DESIGNER NO.DWEL. NO.� Sai~ � n NO. �' ADDRESS �75 UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION p� OWNER•BUILDER DECLARATION SPR/ADD/REM O --.p- i MEREBY AFFIRM UNDER PENILLTY OF PERJURY TH�T i AM EXEMPT FROM THE CONTRACTORS LI� G7fHJe/C8fP0(1 W -C�NSELAWFORTH[FOLLOWINGREASONiSEC.703?.58USINESSANDPROFES510NSC�DEANVCITVOR (n _.C� OOUMYNMICHREOUWESAPERMITTOCONSTqUCT,ALTER,iMPROVE,DEMOiJSH,ORREPAIRANYSTRUC- W PgIlO/DBCk W NRE,PRIOR TO ITS I59UMlCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� W � STA7EMEIY�iHAT HE OR SME IS LiCENSE�PURSUANT TO THE PF�VIS�ONS OF THE CANTHAC70R5 u� --:'� -CENSE LAW(CNAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINESSAND PRD- � POOUSp2 --FESSpN500DE�ORiFIATHEOflSHE1SE1(EMPTTHEREFROMANPTMEBASISPORTHEALL'cGEDEXEMP• (!f V- �TIIXd.ANYVKK,ATiONOF5EC710N7031.58YANYAPPIICANTf-0RAPERMITSUBJECTSTHEAPPLICAN77o Z R¢-ROOf �� - _� .A CIYIL PENAL7Y OF NOT MORE THAN FNE Ht1NDRED DOLLARS(f5a0).): � ❑I,ASOWNEFOFhIEPFOPEflTY,ORMYEMPLOYEESWITHWkQE5A9THEIR50LECAMPENSAiION, CO�i1rti0�Cial -� --YALIDOTHE WOHI(AND THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.7046,BUSI� �J -� NESS AND PHOFESSIONS CODE:THE CANT7kCTOqS L�CENSE LAW�OES NOT APPLY TO AN OWNER OF � PROPERTY WHO BUILDS'JR IAIPROVES THEREON,AND WHO OOES SUCH Y/ORKHIMSELFOR HERSELF Oq -� .THHOUGI4MISOflMEROWNEMPLOYEES,PflOV10EDTHATSUCHIMPROVEMEhTSARENOTINTENDEDOP. � -Q ,--OFFERED(ORSALEIFHOWEVERI�EBI11L61NGORIMPNOVEAIEPI�ISSOLDWiTHINONEYEAROFCOMPLE - - . ..-.Z .-TlON,THE O'NNERAUILDER WILL HAVE THE BURDEN OF PflOVNJ6 TfiAT HE Ofi S4E DID 1lOT BUIID OR � - - - � _IMPROYE FOR THE PUPP0.5E Of:ALE). - l . ❑I.AS ONMEPOF THE PflOfiERiY,AM EXCLUSIYELY CONTRACTMG WITk LICEY5ED CONTRACTOP3 -�- �TO CONSTNUCTSHE PR0.IECT(SEC.70d4:OUSINESSANO PROGESSIONS CODE:TF:E CONI'qACTORS�I- V21113Ii0n � � ADJ.AREA - :W. --CENSEUWDOESNOYRPPLYTOANOWNEftOFAVROPERT'WHOBUI�DSORIMPflOYE57HEREON,AN� - � .NMOCONTMCTSfORSUCMPROJECT5WI7HACONTHACTOMS)UCENSEDPURSUAMTOTHECONTHAG QUANTITY DESCRIPTION FEE TOHS 110ENSE UW.). -� ❑IAM F�(EMPTtlNDER SEC. 8.8 RC.fORTH�S REASON Q T� U � ¢ DATE OYnJER F- Z ' W ..Q LlCENSED CONTRACTORS DECLARATION W .� IHEflEBYA.FFIRMUNDEiiPENALNOFPERJUHVTHATIAMLICENSE�UNOERPROVI510N50FCHAPTER � d i(COMMENCING WITN SECTION�oa0)OF DIVi510N 30�THE HUSME55 AND PRO�ESSIONS CODE,AN� Z _.�. MY LICENSE IS IN Fl1Ll f-0RCE RNQ EF�T. f�r _ -- { �� C.f� �,-�: m -� UCENSE;LA�S���t LIC.N �� + ' ��5� j :U DATE � 1 Aj���) � CONT�" R � ) d W - . , ._� _ WORKERS'CpMPENSATION pECLARATION . . ¢. . - -.� iHEHFBYAFFIRlAUNDERPENALNOFPESiJ�RYONEOFTHEFOLLOWINGDECLARATIONS: Z �---Z _IMAVETNDN/�lLf.9A1NTAiNACEflTIFlCATECFCf3NSErTOSELFiNSUREFOHWORK'eHS' x Q COAAPEN5ATION,AS PROVIDEJ BY SECTI4N 37Go OF TNE LABOft CODE,FOR THE PERFOqMANCE U O OF7HE ri�JFK FOR WNICH THiS PEflM1T IS ISSUEU. � W _I HAVEPND��LL MAIM/JN WORKERS'COMPENSATION INSURAhCE,AS RE�UIRED BV SECTION -Q. 37iAOriHEL490R(X9JE,FORTHEPERFORMf�4CEOFTNENiORiCF�}p'WHICHTHISPFRMITIS SSUEO.MU'. S'CO SA'iION INSUFANCE OAR R ANb c1['CY NUMBER AfiE: CONSTRUCTION -���� � �: � > onaa�Ea - ' PIAN REVIEP✓ z POLICYNUMBER '� %^ / �` �- 'e=-- � ELFCTRIC _ 4 ..� .(n+5s[ciprrrtE�noieEcot�ErEoa=ii-��E�+.ii�swrtavEFa�.uOr�Eoca.uaS�Stooloa�Ess} PLUMBING W Z ICER�IFYTHATINTHEP'cRFORMA�:CEDFTHEW�RKFORWHICHTHISPERMITISI55UED,l MECHANICAL �C�S� £D C) ��S(�(� - - --.:�"-_ SHALtNOTEMPLOYANYPEfl50NINANYMANNERSOPSTOBECONESUBJECTTOTHE - - - �+�t �.�E,I� - WORKERS'COMPENSATIONLAWSOFCALIFORNfA,ANDAGHEETHATIFiSHOUt�BECOM1tE INSPECTIONFEE �_ SUB.IECT TC THE VYJRKERS'C041GENSATION PROVISIONS OF SFCTION 3'/00�F 7HE LABOR q�r �J{�y� y��A p�f���''y ^�� � CODE.ISHALLFOR.THWITHCOM�PLYWi7HTH05'cPflOVISiONS. ISSUANCE `��$yAy g3 �Jgr{�1�p1.t11L'91YL�JlYL�a �y�--� ��,y ..,p �ATE: APPIICANi _ SMIP �4.JAf.�ALVl3.ftiltlif�'8i'L'..1 d. `1 C� -j- WARNING FAIIURE TO SECUFE WORKERS'�MPENSATION CAVERAGE IS UNI.AWFIJI,AND SHAI�BE ENEP�GY PIC .� SU&IECTANEMPIOYEflTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT OOLLARS(5100.000).IN PDDITION TO THE COST OF COMPENSATION,OAMAGES AS PFOVIDED FOR IN :-�_ SECTION37080FTHELABORCOOE,INTEREST,ANDATTOR4EY'SFEES. RETENTIONFEE: _,Q, CONSTRUCTION LENDING AGENCY PRE-ALT FEE: . - Q� 1 HEHEBY AFFIfiM IINDEN PENAL7V OF PERJURY THATTHERE IS ACONSTHUCTION LENDING AGENCY - n- FORTHE PERFORMANCE OFTHE WO�K FOR WHICH THIS PERMIT IS ISSUED(SEG 3097,CIV.C.). . - Z. W -�- LENDERS NAME -f--: IENDERSA�DRE55 �.w. IAGREETOCAMP VVWITH�LGTVANDCCA N OROINANCESAN�STAT�ELAW ARELATWGTOB�I�NG TOTAL FEES � ��Q� � ti CONSTRUCTION,AN�MEREOY AUTHORIZE REPRESENTATIVES Oi TiIS COUNTY TO ENTER Ui'ON THE - ._z_ ABOVE-MEMIONED PflOPERtt A�INSPEGTpN PURPOSES. 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