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HomeMy WebLinkAbout16812 (40) CITY OF DIAMOND BAR � ---�i``� -- DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES I a_ �,.� 21�25 E.Copley Drive (909}860-3195 Fax(909)861-3117 PRESS "`%.���' BUILIDING PERI�IIT APPLICATION FIRMLY o� JOBSITE APPLICATION—, � � ( NUMB R t�� � �^ #/C ADDRESS�9��I CCS��p_�p"���1��a �tV[�: DATE d o� ISSUE TYPE OCC .- APN LOT TRACT DATE CONST, GROUP p OWNER �1i� 0��� aiiY�.a�q�, ADDRESS � � ' ZONING SETBACKS z CITY�$9��►iY1e'�1t5� '�113 ZIP TEL. �� � FRONT RW ❑ o APPLICANT �l�V �, �R9'��9��, TEL.�jg+��a �.���,. REAR ❑ Z $� �— SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR �" SIDE ❑ � ADDRESS J1 . �� � CITY ZIP TEL. PROPOSED USE oARCWENG/ � iz DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIHM UNDER PENALiY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWINGRE4SON(SEGJ031.SBUSINESSANDPPOFESSIONSCDDE:ANYCITYOR U COUNTYWHICHREQUIRESAPERMITTOCIXJSTRUCT,ALTER,IMPROVE,DEMOlISH,ORREPAIRANYSTRUC- W PdtiO/DBCk Z Tl1qE,PRIOfi TO ITS ISSl1ANCE,ALSO REO�IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNID w'� STATEMENT THAT HE OR SHE IS UCEN$ED PURSUANi TO THE PROVISIDNS OF THE CONTRACTOfiS LI- w � . CENSELAW(CHAPTEP9(CAMMENCING'�WITHSECTION70o0)OFDIVISION30FTHEBUSMESSANDPRO- � PDOVSPB FESSIONSCOD�ORTHATHEORSHEISEXEMPTTHEREFROMAN�THEBASISFORTHEAILEa�EXEMP- � �. TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUEJECTSTHEAPPUCANTTO Z Re-Roof �� .� +— �� ACIVILPENALTYQFNOTMORETHANFIVEHUNDRE��OLLARS(5500).): � ❑I,ASOWNERDFTHEPROPERTY,ORMVEMPLOYEESWITHJNAGESASTHEIRSOLECOMPENSATION, � CommBfCi&I - Z WILL DO TNE WORK,AND THE STRUCTl1RE IS NOT INTEN�ED OR OFFERE�FOR SALE(SEC.70A6,9USI- J � NE55 AND PROFESSIONS COOE:11-IE CONTRACTORS LICENSE LAW DOES NOTAPPLV TO AN OVJNER OF ? PROPEFffY WHO BUILDS OR IMPROVES THEREON,AN�WHO DOES SUCH WORK HIMSE�F OR HEaSELF OR �. THfYDUGHHISORHEROWNEMPLOYEES,PflOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOF m Q� OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGOftiMPPOVEMENTI550IDWITHINONEYEAFOFCAMPLE- Z,, TION,iHE OYYNER-BUIL�ER WILL HAVE THE BUROEN OF PHOVING THPT HE OFi SHE�IO NOT BUILD OF = IMPROVBFOR7HEPURPQSEOFSALE�. W�, �I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS [[. TO CONSTRUCT THE PROJECT(SEG 7044,BL151NES5 AN�PROFESSIONS CO�E THE CONTRACiOqS U- VeI112[IOII ADJ.AREA W', CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND ' �� WHOCONTRACTSFORSUCHPFOJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTPAC- QUANTITY DESCRIPTION FEE � � TOFlS LICENSE LpW.). � ❑I AM E%EMPT UNDER S�C. 6.&P.C.FORTHIS REASON Q � U � � DATE OWNER U Z W o LICENSED CONTRACTORS DECLARATION W ¢ � I HEREBYAFFIRIA UNDER PENALTY OF PERJURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER � �' 9�COMMENCINGWITHSEC710N7oo0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AN� � ,LX MY LICENSE IS IN FULL FORCEAN�EFFECT. m � LICENSE CLASS LJG N0. - � U DATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION � Q � IHEflEBYAFFIFMtUNOERPENAITYOFPERJURYONEOFTHEFOLLOWINdDECLARATIONS: Z - Q � IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTiOSELP-INSUFEFORWOHKERS 2 COMPENSATION,ASPROVIDEDBYSECTION370oOFTHELABORCODE,FORTHEPERFORMANCE U ¢ OFTHEWORKFORWHICHTHIS�PEPMITISISSUED. � � w _IHAVEANDWILLMAIMAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION +'��p Q 37ou OFTHE LABOR C��E,FOP THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS �� .0/y ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIEFAN�POLICYNUMBERARE: CONSTRUCTION ���" J j cnaRieA PLAN REVIEW Z, POUCY�NUMBER ELECTRIC ¢, 0 (THISSEC'fIONNEmNOTBECI�MPLEfEDOFhiEPERMRISFORONEHUNDREDCOLL4RS�S10�ORLESS). PLUMBING � lLl Z, ICEflT1GYTHATINTHEPEFFORMANGEOFTNEWORKFORWHiGHTHISPEftMITI5155UED,l MECHANICAL C,�S SHALL NaT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECf TO THE � � WORKERS'COMPENSATIGN LAWS OF CALIFORNIA,ANO AGR=E THAT IF I SHOUL�BECOME INSPECTION FEE = SUBJECTTOTHEWORKEftS'CCjMPENSATIONPROVISIONSOFSECTION37000FTHELABOR �1y CODE,I SHALL FORTHWITH COMPLY WITHTHOSE PROVISIONS. ISSUANCE �e/�.'1.' � SMIP "''�� p �ATE: APPLIGANT. J WARNING FAIWRE TO SECURE WOflKERS'COMPENSpTION COVEFIAGE IS UNLAWFl1L,AND SHALL 8E ENERGY P/C � SUBJECTANEMPIOVERTOCFIMINALpENALTIESANDCIVILFINESUPTOONEHUN�REDTHOUSAN� ENERGYPERMIT DDLLARS(S7o0,000),IN ADDI710N iD THE COST OF COMPENSATION,DAMAGESAS PFOVIDE�FOR IN J SECTION 37080FTHE LABOR CODE,INTEREST,AItlDARORNEY'S FEES. RETENTION FEE: P � � CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O �, IHEREBYAFFIRMUNOERPENALTVOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAOENCY FOR 7HE PERFOFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30W,CIV.C.). . Z W j LENDER'S NAME 1— LENDER'SA�DflESS � TOTAL FEES �2���.,� � ICERTIFYTHATIHAVEREADTHISAPPLIGA710NANGSTATETHATTHEABOVEINFORMATIONISCORRECT. w IAGREETOCOMPLYWIiNqLLCITYANOCOUNTYOR�INANCESANDSTATELAWSRELATINGT06UIL�ING � CONSTRUCTION,ANDHEREBYAIf�HORIZEFEPRESENTATIVcSOFTHISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS 0 J � � PERMITfEE NA{AE(PRINT) � } ' C� / ' ..� e�� � SIGNHTVREOFPERMITTEE DATE , = RECPT.NO. 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