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HomeMy WebLinkAbout14459 (8) � 6�' 1� CITY OF DIAMOND BAR ' = DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 PRES$ � ��'9�°, BUILDING PERMIT APPLICATION FIRMLY � -- _. _ , o ADDR'ESS �I�� �(3:�\��✓ DATEIGATION f��I A U�� NUMB R ��J #/C (l c� ISSUE TYPE OCC APN-� lOT TRACT DATE CONST. GROUP p OWNER �l f-ny��i.-���� " ADDRESS �Ga�� ZONING SETBACKS Z CITY ZIP �--- TEL. PRONT RW ❑ g APPtICANT TEL. REAR ❑ Z SIDE/SIDESTREET RW ❑ � CONTRACTOR YL i v. ,,.,. SIDE ❑ � ADDRE S K � � CITY ZIP� 7EL. � ' �-Lz��S PROPOSED U$ !� , w ARCHlENG! ' � DESiGNER N0.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �_ . OWNER-BUILDER DECLARATION SFR/ADD/REM O � 1 HEREBY AFFlRM UNDER PENALTY OF PERJUFY THAT i AM EXEMPT fROM THE CANTRACTORS LI-- .G8I89B/C0IP0(I -W CENSEIAWWRTHEFOI.LOVJINGPEASON(SEC.7a31.5BliSWESSANOPFOFESSiONSCADE:ANYCITVOH - (n - - _U� COUNTYNh11CHREQUIRESAPERM�TTOCONSTRUCT,ALTER,IMPROVE,DEh!OLISH,OPFEPAIRANYSTFUC- W- Py116/D9CI( W- TURE,PRIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APPIICANT FOR SUCH PERMITTO FILE A SIGNED (ll . � STATEMENT THAT HE OH 3HE IS LICENSE�PURSUANT TO THE PRDViSIONS OF TNE WNTRACTORS Lb ,�- - . _�.: CENSE LAW(CHAPTEFi B(COMMENCING WRH SE�TION�000)OF OlVIStON 30�THE 9USi�ESS M!D PRO- POOUSPd PESSpNS GODE)OR THAT HE ORSHE IS EXEMPT 7HEflEFROM AkD THE BA515 FOR THE ALlEGEO EX:MP- �V TION.ANYVIOLATIONOFSECTION7037.5BVANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTTO � Z Re-Root - �- ACIVILPENALTYOFNOTMORETHANFIVEHUNDFEOOOLLARS(5500).): - - ��. ❑I,ASOWNEflOFTHEPFOPERtt,ORMYEMPLOYEESWITHWAGESASTHEIR50LECOMPEN9ATION; -�_ COrt1ffIBlCI01 �. W�LL 00 THE WORK AN�THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7044,BU51- - J - NES3AND PqOFES510NS CODE:THE CONTRACTORS UCENSE LA4J DOES NOTAPPiYTO A.4 OWNER OF- _,� - �- PibPEHiYWNO8U1L�50RIF7.PROVES7HEREON,ANDWHODOESSUCHK'ORKHIMSELFORHERSE:FOR - -.CL THftWGXHI50RHEROlYNEMPLOYEE5,�ROV1�7E�THATSUCHIyPftOVEM11ENTSAHENOTINTEN�E�OR - - m __`Q_ OFFERE�FORSALEIF,HOWEVERTNEBUILDINGOAIMPROVEMENTISSOL➢WRHIYO�EYEAROFCOMPLE- - - --- - - --SION;THE-OWhER$UILOER WILL k1AYE THE BURDEN-OF PROVING THhT NcOflSHG-�ID NOY BUIL[3 OR ------ --- _,_. IMPROVEFOATNEPURPOSEOFSRLE). - � - - - - � ,W ❑I,ASOWNEHOFTHEPROPERfV,AMEXCLUSiVELVCOMflACTiN6WiTHLICENSEDCONTRACTORS � :'Q- TO CONSTflUCT h1E PRQIECT(SEC.lDu,@USWESS AND PPOfE6310NS CODE:THE CO4TRACTOAS LI-- �.��,� Vd�Udtl011 ADJ.AREA - -�W-- �CENSELAWDOESMOTAPPIYTOANOWNEftOFAPROPEHTYWHO6U!LDSORIMPROVESTHEREON,RND - - -�_ -WHOCONTRACTSFOR5UCHPRQIECTSWITHACONiRACTOR(S)LICENSEDPURSUANT70THECONTRAG QUANTITY DESCRIPTION - PEE - - TORSLICENSELAtY.y. . . -�: . .❑1 AM EXEMPT UNDER SEC. . .. . � .. . B.&P.Q FOR THIS REA30N -.-Q . . _� ` LJ _. .. - - . - . . .. .:LL _ . - . . . :. H - . - DATE OY.'NER _ � - � ,'p LICENSEDCONTRACTORSDECLaRATIOV ' W -:�' IHEflEBVAFFIRMUNDERPENALTVOFPERJURVTHATiAMIICENSEDUNDEAPaOVISlONSOFCHAPTER :._ � ¢,- 9(COMMENCINflN1THSECTiON7W0)OP-DIVISION30FTHEBUSINe55ANDPROFE55!ONSGO�E.AYO - z - ±X_- MiY LICENSE IS Itd ft1LL FONCE ANO EFF£CT. - . _ m - U! u .�o__ LICENSE C 5 �� � LIC.NO..- ��� \� - � } J - ;� �.OA � O V� - CONTHACTOR � ��0-- . . W '�@ .a� . ` \\ WORKERS.f.OPdPENSAT(ON pFCLARATION . . � -�� . . .. . . . . �, Q �. IHE YAFFIHMUNDEflPENALTYOf9ER1URYONEOFTHEFOlLOW1�:GDECLARATIONS: - � U I fn.: :9 Z .�0� IHRVEAN�WILLMAINTAINACEflTIFICRTEOFCONSENTTOoEIF-INSUR'cFORWOflKERS' � -�S - �� COAlPENSATION,ASPHOVIDEDBYSECTION3�ooOFTHELASOftCODE,FORSHEP'eRFORAiR�CE -:__ `U1 - . � OFiHEWORKFORWHICHTHISPEflMITI5155UE0. � _ � ,� W- HAVEANDWILLMAINTFUNY70RKER5'COMPENSATIONINSl1RANCE,ASREOUIREDBYSECTION - =Q. 00 Of hIE LABOR CODE,WA fHE PERFORMRNCE OF THE WORK FOR F4HICH?HIS PEqMIT S � I UED.MY WpORKERS'WMPENSATION IN RA.NCE CARfl1ER RIrD POLICY NUMBEfl AFiE f � CONSTRUCTION ��f l _ -'�_�� . CA IER `����`'� �.+y.1 � i PLAN REVIEW _��_ , _Y MJMBER ��I��.Y�O 'V V i ELECTFIC �a SSECTIONNEIDNJTBEOOMR.EfmOF7F�PENN1'!SWRaNEhiMdN2ED�OLIAFS(E��)�LESS) _� PLUMBING 0. :W_ � Z. 1 CERTIF1'THAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS FERMIT IS ISSUED,1 ! MECHANICAL (� . SHALLNDTEMP40YANYPEfl50NiNANYMANNER50ASTOBECAME5U9JECTTOTHE- _ - - � - - - '- - :�_� WOPKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGPEETHATIFISHOULDBECOME , �--1tJSPECTtONFEE -- - -���?` SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECT1043�ooOFTHELABOR- - � �] GOOEJ SHALL FORTiWITM COMPLY W I7H THOSE PflOVI510NS. . ISSUANCE Y P -.-p�- DATE: APPLICANT: . . . . . -. .SMIP . .____ p� � . 3�_ . W g g _ �: WAPNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS U4LAWFUL,AND SHALL BE ENERGY PIC � `-)� F'~'.� "�� _ "�' -SU&IECTANEMPLAYERTOCFIMINALPENALTIES-ANDCIVILFMIE3UPTOONEHUNDRFOTHOUSA4� --- "�"ENERGYPERM�T-- - 1��t1�� -��r�a7';- - OOLLARS(S10o,000),INADDITIONTOTHECOSTOFCOMPENSATIO�,DAMAGESASPHOVIOEDFORIN �� �-���s���;y�@ �-J"- SECTION37080FhIELABORCODE,MTEflEST,ANDATTORNEV'SFEES. `�' � � - '-�'�€ ;¢_ �.RETENTION FEE: -a'�_�r��� �,d-_ CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: "< t� O, _ -���..-�-.: IHEREBYAFFILIMUNDENPENALTVOFPERJI/RVTHATTHEREISACONSTRUCTIONLENDINGAGENCY FORTHE PFRFO(1MANCE OFTHE WOFiK WH WHICH THIS PERMIT IS ISSUED(SEC.3o97,CN C.). .Z W:- ._ LENOEH'S NAME___ `,�' F-�` LENDER'SA�DRESS - -�-�` ICEflTIFVTHATIHAVEREADTHISAPPUCATIONANOSTATETHATTHEA60VEINFORMATIONISCARRECT. TOTAL�EES ---�� IAOREETOCOMPLYWITHALLqTVANUC�UNTYOR��NANCESANOS7ATElAWSRELATINGTOFiUILOMG � -:�� CONSTRUCiION,AND NEREBY AUTrbRIZE flEPRESENTATNES Of THIS COUNTV TO ENTER UPONTHE �,Z ABOVE-MENTbNED PfiOPEflTY FOR INSPECTION PURPOSES. COMMENTS �.�. � � � ����-�-�G� - m- PERMITT NE� AME(PR' - __._ __' . _ _._—_- _' . .,(!j- �V�. - ,y- SIGNANREOPPERMITfEE DATE . - _._ RECPT.NO. PAID BY VALIDATION ~' WHIT partmen[Copy,YELLOW--Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN— licanfs Co py, PY. 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