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HomeMy WebLinkAbout11912 (5) � � CITY OF DIAMOND BAR —� ---�1� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES • �—� � - 21660 E.Copley Drive 5uite 190 � (909)860-3195 Fax(909)861-3117 PRESS � '9^° BUQ.DING PERMIT APPLICATION FIRMLY A DDRiESS � �� � s f DATEICATION r/������ NUMB R i���q/C / T�'PE OCC � APN OT • TR CT D TEE CONST.� GROUP p OWNER �1T ��/� IJI� � C�_ o ADDRES S_�d,� r�s � Z ONING SETBACKS z CITY ZIP TEL. FRONT Ryy n $ APPLICANT TEL. REAR � — � — SIDE/SIDE STREET _ pW U CONTRACTO j ' ( � �"� SIDE -- � ADDRESS � � .-- ' a� �--- o CITY (��(J�/�,(•{— ZIP_ TEL. ��� ... PROPOS[D U5E�z� _ wi,--. ' .� �j,91hC� � w ARCWENG/ ` � ` � z DESIGNER Z-�� a ADDRESS NO.DWEL. NO. NO. UNITS_ y C17y Z�P TE� _ STORIES ____�____BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION O SFWADD/REM p I HEREBY AfFIRM UNDER PENALTV OF PEHJURY 7HAT I AM EXEMPT FHOM THE CAN7NACTOBS LI. Gafege/CB�pOff W CENSEUWFORTHEF�.LOWINGREASON(SEG7037.58USINESSANDPqOFF5510N5CODE:ANVCITYOR (n WCOUfJTVWHICHqEWIRESAPEHMI7TOCONSTRUCT,AL7ER,IMPqOVE,DEMOLISH,ORREPAIRANYSTRUG � �p A NRE,PRqq TO ITS ISSUMICE,ALSO qE�U1RE5 THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNE[1 W Patio/Deck ��,,�� � STATEMENT 7HAT HE OR SHE IS LICENSE�PURSt1ANT TO THE PROVISIONS OF THE CANTpACTOR6 L6 � CENSE LAW(CHAPTEq p(CWdMENCING WITH 6ECTION 7000)OF OIVISION 9 OF THE BUSINE55 AND PRO� V' POOUSPB � FESSqNSCODE)Ofl1HATHFORSHEISE%EMPTTNEREFROMANI)TME�ASISFOfl7HEALLEG[DEXEMP� � T�ON.ANYVIOLATIONOFSECTION7037.6BYANVAPPLICANTFORAPERMITSUBJECTSTHEAPPUCANiTO Z Re-Roof � ACMLPENALTVOFNOTMOREAi{WFNEHUNDREDDOLURS(5500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEM.PLOYEESWITHWqGE5A5iHEIRSOLECAMPENSATION, � Commercial . VtILl00 THE WOHK,AND THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SAIE(SEC.7044,9USI- J N NESS ANO PROFESSIONS CO�E:THE CONTRACTORS LICENS[LAW DOES NOTAPPLY TO AN OWNEfl OF � PppPEqfYW110BUILD50RIMPROYESTTIEHEON,ANDWXO00E55UCHWORKHIMSELFORNEHSELFOR -' � THROUGHHISORHEROWNEMPLOYEES,VROVIDEO7HATSUCHIMPfiOVEMEMSAqEKOTIN7ENDEDOR ' CD W OFFEREDWRSALEIF,HOWEVER7MEBl11LDINGORIMPROVEMEN7135oLDWl1'NINONEYEAROFCOMME- �.� TION,THE ONRJER�BUILUER WILL HAVE THE BURDEN OF PROVING TNqT HE OA SHE OID NOT 9UII.0 OR � IMPROVE FOR TME PURPOSE OF SALE). f.11,A50WNEROFTHEPROPEfITV,AMEXCLU5IVELYCONTRACTINGWITHLICENSEDCONTRACTORS ' �� TO CONSTRUCT TH[PROJECT(SEC.70M,BUSINESS AND PROFESSIONS CODE:TME CONTRACTORS U� � V81Ufll10� ADJ.AREA ' S� CENSELAWDOESNOTAPpLYTOANOWNEROFAFROPERTYWH09U1LD50HIMPFlOVESTHE(iEON,ANO ' —""' -" -------- �--�---�--� F: NRfOCONTRACTSFORSUCHPRQIECTSWITHACONTRACtt1R(S)�ICENSEOPURSUIJJTTOTHECANiHAC- i � QUANTITY DESCRIPTION Y Toas ucENSE uw.�. FEE o; O IAM EXEMPT UhOER SEC._ _____,__B.$P.C.FORTHIS REASON - Q ' �. U LL' DATE'__ ONTIER... ' __' � A. w � Z. _'_._..__.— U C.�-� ��� LICENSED CONTRACTORS OECLARATION W � . . I HERFBY AFFIRM L'h'DEfl PENALTV OF 7ERJUHY 7HAT I AM UCEN3ED UN0[R PROVISIONS OF CHAPTER � �� p.�, 8(COMMENCINO WI7M SECTION 7000)OF DIVISION 30FTME BUSINESS ANO PROFESSIOV5 COD[,ANU Z X MY LICENSE IS IN FULL FORC AND EFFECT. • �- m W. � d' LICENSE CLASS „ LIC.NO. ��� _ � � ; � V��. DATE_ w � I � CONTRAGTOR !` d W. �� WORKERS'COMPENSATION DECLRRATION G'j"'� � Q �' IHERE9YAfFIRMUNOERPENALTYOFPERIIJRYONEOfTHEFOLLOWINGDECLAHATIONS��t/� i /� U U� IM1_ f; Z 0. IHA AND�LLMAINTAINACEflTIFICRTEUFCANSENTTOSELF�INSUREFORWOHK. ���,` a �' P = �. PENSATION,AS PROVIOED BYSECTION 3lo0OF THE LABOR CODE,FOR TIIF PERF M�NC U F TME WOqK FOR WMICH THIS PEiiM1T IS ISSUE�. W W> � � _INAVEANDWILLMAIMiAINWORK[F75'CAMPENSATIOQNINSURhNCE,ASR[OUIRFUBYSECTION � — Q. 37000FTHE1_ABORCO�E,GORTNC�GRFORMANCE FTHEWORKFORWHICHTHISPERMITIS J � ' S� DPOLICYNUNC a -: CONSTRUCTION .._ .__ y , . ._...—. "'__ � : j. CARH ER Y WOP.KE _OMP IS TI iNsuRa .%qqRieR r p�pN REVIEV✓ �G _".... ...._... :' Z� POLICYNUAIBE .j. • �c� ELECTRIC � f � .. Q � i�'��� -------- ..._—..... __....—f._--_t_3 ', � (MISSECiI(NJNE�NOTBEWM1�IEfEDOF7HEPERMfT13F'ORIXJ[INMMEDDOLWRS(b10D)OfiIESS}� PLUMBING .._,_____._ W ...—._._ ._.. ..—_"— Z. I CERTIFV THAT IN THE PEHFORMANCE OF THE WORK FOR WHICH THIS P[RMI71515SUED,I MECHANICAL CJ.. SMPILNOTEMPLOYANYPERSONINANYMANNERSOASTO�EC.OM[SUOJECTTOTHE �� - '--' '-'---- .;� (q WORKERS'COMPE4SATIONLAWSOFCALL�OHNI AN�AC,REETHATIFISHOULDOCCOM[ INSPECTIONFEE __,.___._._.. �f_ � • _'� SUBJEC T�T��KERS'COMPENSATIONP !SIONSOFSG�37000FTHELABOfl -- � �--- "—��rr � COOE,I MA4 T 1WITH COMPLY WITH THO R I IONS. ISSUANCE �,.+, �, W' DATE:__'_ �, . APPLICANT: � SMIP ,� � : J WARNINL.FAIL RL TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUNTLIL,AND H L BE ENERGY P/C J . .._'_—' "'—"___....—__._. �`. SU&IECTANEMPLOYEHTOCHIMINALPENALTIESANDCIVIIFINESUP100NEMUN�REOTH AN� ENERGYPERMIT .___ ..____., __ f .� OOLURS(f 700,000).IN ADDITION TO THF.COST OF C�MP[NSATION,DAMAOE5 AS PROVIDED FOR IN J, SECTION 37080F hiE LABOR CODE,INTEREST,AND ATTOHNEY'S FEES. OC� RETENTION FEE� O, CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �, • _ � �: 1 HE{7E6Y AFFIHM UNDER PENALTY OF PEiUUii`/THAT THERE IS A CONSTRUCTION LENDING AG[NCY �' FOftTHEPERFORMANCEOFTHFWORKFORWk11GITHISPFRM171SISSUED(SEC.3097,CIV.C,). —"'— �a --.—_ w �� � I.EN�EWS NAME __' .. __'_"" ""_"' —.' "_' '—._. F— LEN�Efl'S.M1OOflC55__,__ / w 1 CERTIFYTHAT I HAVE READ THIS APPLICATION AND STAI"E THAT THC ABOVE INFORMATION IS CCRRECT TOTP.L FEES . �i'f�� j( D � 1 AGREE TO COAAPLV WITH All CITY AND COUNTV OHDINANCES AND STATE LAWS RELATING TO BUILUINO / � � CONSTRUCTIDN,qND HEflEBYAUTHOflIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON TME /- `� Z �80VEMENTKKJED PFOPERTY WR INSPECTION PUHPOS[5. COMMENTS_�y��� .�J O� 0 � � __ J � � —'_' ' _'_'—_ m f+ERMITT AUE( INT) C5�7/v r -- _"_' Q �//y��► .— �ry SIGNANqEOFPERMITfEE DATE r �� � —' ' . � RECPT.N0. __PAI�BY J��� . 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