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HomeMy WebLinkAbout10364 (5) i � ----1'� CITY OF DIAMOND BAR f; COMMUNITY DEVELOPMENT DEPARTMENT r �,,,W 21660}i.Copley Drive Suite 190 PRESS � (909)860-3195 Fnx(909)861-3117 � "��'� BUILDING PERMIT AP,PLICATION _ FIRMLY � } JOBSITE � � � � � � APPLICATION, PERMIT I � P/C o ADDRESS r�I cYx �,,.. 3� - Y �. : ' � ' , DATE ' . NUMBER /U� � � � � �SSUE � ��TYPE OCC � � APN LOT � TRACT DATE ' CONST. GROUP ' � OWNER �?-�.��.,.. , / ;:!i�� � .3_�."'_ � � ��' '���� ty ZONING SETBACKS o ADDRESS .�_,y ; w �g r 1 � !r:+ � fi FRONT _ _ RW (-1-- Z CITY�'d/��F'f':P6, r, �IF���__ TEL�%^��-.{•r.; - :L.. APPLICANT � TEL._._ REAR CJ ! Z SIDE/SIDE STREET RW fl.__ -� ' Q CONTRACTOR - • -� �5��--" � ' SIDE L i � ADDRESS x;;r a„r,�T,�;_ i�, PROPOSED USE �'� I i ti fJ � � CITY r ♦ 7,�,_ ZIP =e1�u.jTEL.�h7'/. 1-/.�l�J ��,.r .� 'Y L-'' w ARC NCaH�� > - � I i z DESIGNER NO.�WEL. NO. NO. � � ADDRESS — — -- UNITS STORIES BEDROOMS CITY ZIP _ TEL. ____ �' DESCRIPTION SQ.Ff. FACTOR PSF ADJ_AREANALUATION � � OWNER-BI:ILAER DECLARATION SFRIADD/REM p 1 HEFEBY AFFIRM UNDEH PENALTV OF PERJURV THAT I AM EXElAPT FROM THE CONTRAf.TORS LI� Gdfd9BlC3fpOfi 0 W CENSELAWFORTHEFOLLOWINGAEASON(SEC.7031.5BUSMESSANDPROFESSIONSCOD[:ANYCITYOR (n _ U CDUNNWHICHREQUIqESAPERMRTOCONSTRUCT,ALTER.IMPFOVE,DEMOLISM,OHREPAIRANYSTRUC- W Pd110/DBCIf W TURE,PRIOR TO ITS IS5UANCE,AL50 RLQUIHES THE APPLICANT FOF SUCH PEHMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS UCENSED PUFSUANT TO THE PROVISIONS OF THF f.ONTRACTOFS LI- � CENSE LAW(GMAPT[R 9(CAMMENCING WITH SECTION 70D0)OF DIVISION 30F THE BUSINE55 AND Pq0• � POOVSPB FESSIONS CODE)OR THA7 HE OR SHE IS EXEMVT iHEREFROM AND THE BASIS FOH THE ALIEGED EXEMP- � TION,ANYVIDLATIONOFSECTION7031.SBYANVAPPLICANTFOHAP[RMITSUBJF:CTSTHEAPPUCAN770 Z Re-Hoof � ACIVIL PENALTY OF NOT MORE 7HAN FIVE MUNDRF:O DOLIAflS(SSOD).): � uI,ASOWNEROFTHEPROPERTYORMVEMPLOVEESWITHWAGESAS7HEIR5OLECOMPEN5A71DN, � COmmBlCial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC,704l,6U51� J NESSAND PROFESSIONS CODE:THE CANTflACTORS LICC:NSE LAW�OES NOT APPLY TO AN OWNER OF � PiiOPERTVW1iDBl11LD50RIMPROVESTHEFEON.ANDWHOD0E55UCHWORKHIMSELFORHEFSELFOH � Q THROUGH HIS OR HER DWN EMPLOYLCS,DFOVIDEO TNAT SUCH IMPFOVEMENTSARE NOT INTENDEOOR m W OFFEREOFOHSALE.IF,HOWEVEfl.THEOUiLDINGORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE� 0 TION,TME OWNER�BUIL�ER WILL HAVE THE BUft0E4 OF PROVINC THAT HE OR SHE OID NOT 9UIL0 OR Z IMPFOVE FOR TNE PURPOSE oF SALE�. _ �.�I,ASOWNEflOFTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHI.ICENSF.DCONTMCTOFS � TO CONSTflUCT THE PROJEGT(SEC.7094,BUSINESS AND PROFESSIOYS CODE'THE fANTRACTORS LI- V8IU2I10� ADJ.AFiEA______ W CENSELAWDOESNOTAPPLYTOANOWNEi70FAPROPEPTYWH08l11LDSOflIMPPOVESTHEREON.AND � �' N'FiDCONTRACTSFORSUCHPROJECTSWITHACANiRACTOR(S�UCF.NSEDPUFSUANTI'OTHECONTqAC QUANTITY DESCRIPTION FEE TORSUCENSELAWJ. • J ��. / �-. ."'� " G .r. r- Q ❑I AM EXLMPT UNDER SEC._ _.____.._...._A�8 P.G FOR THIS HEASON � `�✓�°L-''. �l�%�" � � �i .'-----'— � . -�:7 � � Z DATE OWNEF.._. ~ 1 ��. � lr "_"—___'___.._..__— W' 7aJ ' �� _�... �1� .{'"��.. O i � LICENSEDCONTRACTORSDECLARATION W y��`•r�';;a'� �"�;r �_� , „ , ��1 � I HEfiEBYAFFIFiM UN�ER PF.NALTY OF PEPJURV THA71 AM LIGENSED UNDE11 VROVI5lON5 oF CHAPTER � �di �,+'�"'�i.�6'l^'' 4 d� 9�COMAIENCINGWITHSECTIDN704a)OFOIVISIUN30FTHEBUSINESSAND7ROFESSIONSCOOE.ANO � �X MV LIGENS[IS IN FUII FOflCE ANO EFFECT. z m � ��LICENSE GLA55 ____—_LIC.NO. �_.__� � . .... ;.1 `.i ',A 'a�`:!�' V DATE----'-------- CONTRACTOR-'--.'— 0-� j W � � WORKERS'COMPENSATION DECLARATION � , � IHEREO�AFFIRMUN�ERPENAL7YOFPFRJURYONEOF7HEFOLLOWINGDECLARATIONS: � � Z � — Q _�"_ � IHAVEANOWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUR[�O(iVfORKERS' x CAMPENSATION,ASVROVIOEUBYSECTION37000FTHELABORCODE.FORTHEPERFOHMANCE U ¢ =�OFTHEWORKFOfiWHICHTHISPERMITISISSUED. � � 'L� w I HAVEAND WILLMAINTAIN WORKERS'CAMPENSATIOY INSURANCE,AS REOUIREO BV SECTION Q 37000FTMELABDRCOOE,FORTHEPLRFORMANCEOfTMEWOflKFORWHICHTHISPERM1T15 ISSUE�.MV WOP COMPENSATION INSUFANC�CARRIER AND POUCY NUMBER AREE CONSTRUCTION j ...��eC 'L�L'r--�' . • P1AN REVIEW .d� CARRIER___'__ ' -- —_—""_______"__ • Z �+oucv NUMeea—�_J.�%C.� �,� . ... ' _ _._. `R�i rd� ?ELECTRIC -- J ¢ � (IHISSfCT10NNE�NOT�EWN3'LEfEDOFTHEPEWMISFORONEFKMD7ED001.1A0.S(5100�OHLESS). PLUM6ING W Z ICEFi71FY7HATINTHEPERFORMANCf.OFTHEWORKFORWHICHTHISPERMI715155UE0.1 MECHANICAL '(� SHALLNOTFMPLOYRNVPERSONINANVMANNERS9AST08ECOUESU6JECTTOTHE (n WORKEFS'GOMPENSnTIDN LAWS OF CALIFOflNIA.ANU ACHEE THAT IF 1 SHOULU f3ECOMC rI�LSP.F�T10N FEE � Sll&IECTTOTHEWORKEFS'COMPENSATIONPflOVISIONSOFSECTION37000FTN`eLABOfl �_ � COOE,ISHALLFORTHWITHCOMPlVW17HTHO5EPROVISIONS. �SUANC� � � / • p DATE:__ .__. APPL�CANT: _......___._—___._"_— W ENERGY P/C �' WARNING FAILURE TO SECURE WORKEHS'COIAPF.NSATION CAVERAGE IS UNLAWFUL.AND SHALlBE � SUBJECTANEMPLOYEqTOCRIMINALPENALTIESMDCIVILFiNE5UP700NEHUNDREDTIpUSANU ENERGYPERMIT OOLLARS(f100.000).INADDITION TO THE GOST OF COMPENSATION,DAMAGES AS PROVIOEO FOR IN -}-� SECTION 37oB Of THE V+BOR CODE,INTEREST,ANDATTOPNEV'5 FEES. RETENTION FEE: � d CONSTRUCTION IENDING AGENCY pRE-ALT FEE: ___ O � I HEFEBV AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS ACAN51'flUCTION LENOING AGENCY _____ FDIi THE PERFOHAIANCE OF THE WORK FOR WHICN THIS P[RAIIT IS ISSUE�(S[C.3097,CIV.C.). Z W _'__..--_ � LENOER'S NAME_..__ "' _._-".— ____ _ �, �F-' LENOER'SAD�RESS ___'__". __._...._._..'.'--. � I CEFTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE 1180VE INFORMATION IS CORflECT. TOTAL FE ES 'w 1pGflEETOCOMPI.YWITHALLCITVANDCOUNTYORDINANCESAN�STATElAWSRELATINGTOOUILDING � CqNSTRUCTION.ANOHEREBYAUTHORIZEREPRESENTATNE50FTHI5COUNfYTOF.NTERUPONTHE Z A60VE�MENTIONED PFlOPERTY FOR INSPEGTION PUFPOSLS. COMMENTS_._._ 0 \\ �! / �7 �" �_�! �� Y�4��� i�.� : 1�,-.. 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