HomeMy WebLinkAbout12191 (11) 1 � • �'�p'��� CITY OF DIAMOND BAR -- ��-- AEPARTMENT OF COMMUNITY&D I E oCT I 21660 E.Copley Drive Suite 190 �`� �� �'� � � (909)86(�3195 Fax(909)861=3117 �E`S`S � ���9�'� BUQ.DING PERMTr APPLICATION FIRMLY o DDR'ESS�� � S 1 L� , ) DATE CATION� �� tiA7 f NUMQ R � � #/ �:J s��� c� ISSUE TYPE; OCC APN LOT TRACT_ _ DATE CONSV. GROUP p OWNER '� � ����„ ZONING SETBACKS \~""J� " ADDRESS � '� ' ' � W CITY�+�,�' ''j,� ZIP �'1�i�,1 TEL.4', �- "- CJ�I FRONT RW �.------ + � APPLICANT:" ' - ` TEL. t�.-1' REAR ❑__ ' � SIDElSIDE STREET_ RW_ C] __ � c� CONTRACTOR '�s�' • " ��� % r�67+a SIDE C]..___ ,.n..._ , ' a �v ' � ��Q�� �'� Q ADDRES �� � `^'i-l-� � PRAPOSED USE ^ °S.YV'V�(� � � � � CIIY � ,t���,. ..,..,, ZIP <f�TEL.� � -. q 4 :�.x,�,.7 E i-�'i,;(:.�i�me��f�.�.. � w ARCHlENG1 -- �- T'- W DESIGNER ` w NO.DWEL. NO. NO. � a ADDRESS ``'- ' UNITS STORIES BEDROOMS { �, CITY � . ZIP TEL. y � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREA/VALUATION a ,O OWNER-BUILDERD�CLARATION SFR/ADD/FEM Q 1 HEREBY AFFlRM UNDER PENALTY OF PERJURY THAT i AM EXEMPT FflOM THE CONTRACTORS LI- � Gfll'89B/C8fP0(I � W CENSELAWFORTHEFOLLOWINGPEASON(SEC.7o37.5BU51NE55AN�PROFE5510NSCODE:ANYCITVOH � f,U COUNTYWNICHREOUIRESA�ERMITTOCONSTR�CT,ALTER,IMPROVE,DEMOLISH.O(iREPAIRANVSTqUC- W patio/Deck 'W�. NRE.PRIOR TO ITS�SSUANCE,AL50 RC-0UIRES TME APPUCANT FOR SUCM PERMIT TO FILE A SIGNED W , �, STATEMENT THAT HE OH SHE IS LICENSE�PURSUANT TO THE PROYISIONS OF THE CONTRAC70R5 LI- CENSE LAW(CHMTER B(COMMENGNO WITH SECTION 7W0)OF DIV1310N 3 0F THE BUSINESS AND PRO� V' POOVSp2 �"�� fE55pNSCODEJOATMATNEOfl5HE15EXEMPT7HEHEFHOMANDTME8A515FORTHEnLlE6EDEXEMP- .� V�. TION.ANYVIOLA7IONOPSECTION7031.50VANVAPPLICANTFORAPERMITSUFiJECT57MEAPPLICANTTO � Z R8-RaOf ;F. ACIVIIPENALNOFNOTMORETHIWFNEHUNDREDDIX.UR5�i5oo).): .�. � ❑I,MSOYMEROf1NEPROPERTY,ORMYEMPLAYEESWITHWA0E5ASTHFIflSOLECOMPENSATION, � 0 COffl 6fCI0I '� � .�:� VALLOO7HE WOFiI(,AND THE STRUCTURE IS NOT INTENDEO Ofl OFFEflED FOR SALE(SEC.7044,BUSI� .J '�:� NESS AND PROFESSIONS COOE:h1E CONPRACTORS UCENSE LAW DOES NOT 0.PPLV 70 AN 04MER OF �'�.� � PlqPFATYNTqBUIl�50HIMPHOVESTHEREDN,ANOWHODOE55UCNWORKNIMSELFOPHEFSELFOR m � 'i�;. hIROU�FIFII30HFiEflOWNEMPLOYEES,PflOVIDED7HATSUCHIMPHOYEMENTSARENOTINTENDF00R �W� OFFEREDiORSPLE.IF,HOWEVER,THE9UIlDINOORIMPROVEMEMI55ol�WI7HINONEYEAROFCOMPLE- � "0� YpN,THE OWNER�BUILDER WILL HAVE TME BURDEN OF PAOVIN6 TFiAT HE OR SHE 01�NOT BUII.D OR ��' IMPHOVEFORTHEPUHPOSEOFSALE). � �,.W; ❑I,ASOWNEROFTHEPFiOPEHfV,AME%CLUSIVELYCONTRAC71tJGWITHIICFNSEDCANTRACTORS .�'� r v� '•�:: TO CONSTRUCT THE PHQIECT(SEC.TObi,BUSINESS AND PROFESSIONS CODE:THF.CONTRACTORS LI� VBI110S10� „_�tT���` _+1y..�_....4P__�ADJ.AREA ':W;' GENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTVWMOBUILD30FIMPROVEBTHEREON,ANO ��� WHOCONTRACTSfORSt1CHPROJECTSWITHACONTHACTORIS)IICENSEDPURSUAN�TO7HECONTFiAG QUANTITY SCRIPTION F �: TORSIlCENSEUW.). \. �- / .�yp� � �''���, ❑IAME7(EMPTUNDERSEC. _.___8.8P.C.fORTNISflEASON, �. Q � Q""" _ `-��-'Y ��+ l E0;' U a "-�+: —..------ r� L-t C�-'l. �0 ��� �ATE_. OWNER_'..__'___ �. U '+z.: W �. LICENSED CONTRACTORS DECLARATION �j __ .��:^. I HEREBY AfFIRM UNOER PENALT'OF PEFUUH'i iHAT 1 AM LICENSF.O UNDLF PROVISIONS OF CHAPTER , � �Fd7� g(COMMEIiCIN(3YlITNSECTqN7o0o)OF�IVISION30FTHEBUSINESSANOPROFESSIONSCODE,AND � Z X MY UCENSE IS IN FULL FCRCE AND EFFECT. , m i.'W'�" i"� "� .�0,; LICENSE CIASS �.-7 LIC.NO._���ys � � � ;,.� J � pp7E CONTRACTOR. � �� a .��' —'._.... 111' — 9 '��;'. WORKERS'COMPENSATION DECLAFATION �. ,� 1 J $ U — �'N'''� I HEREBV AFFIRAI UNDER PENALTY OF PERJUAY ONEOF THE WLLOWINO OECLAHATIONS: `,;.(A; Q ! ��+•'0�'. IHAVEANOWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWONKENS' ' _ � !.,'�" COMPENSATION,ASPflOVIDEDBVSECTION37ooOFTHELABORCODE,FORTHEPERiORMANCF. ' W � ,, OF7HE WORK FOR WHICH THIS PF.flMIT IS ISSUEO. . � r.n W, � ___I HAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REQUIHED OV SLCTION ,�O!, 370o OF'fHE IABOR CODE,FOF THE PERFORMANCE OF THE WORK FOR WHICH TMIS PERMI715 ��� �� „�, ISSUED.MYWORKERS'COMPENSATIONINSURANCECA`FR�I.ERANDPDLICYNUMBERAfIF_ ' CONSTRUCTION /� a - `�.�!_ `�h,�[ LC IV�:�'_ PL EVIEW . '"� 9¢.' CARRIEFl__ ,/� : — -- 1 :�.�6', POLICV NUMBER_ �.�� � 7 C� •:r `�� : � r • Z � 4 LECTFlIC �1.r� .._----- ._..._...�.�_�_ { a.¢� t � ;;: _ (niss[ci�rvNe�doise�imoFniE�w.ai�s�aaEruxaoaE000u.ws(siao�oa�Essl. PLUMBING stl�`1.....-,-----------_.-----------.------- �. s'��:Z; I CERTIFYTHAT IN THE PERFORMANCE OF 7NE WORK FOR WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL ,_._--_._.__...__ �• ;�(,rs^ SMIILLNOTEMPLOYANYPFHSONINANYMANNER50ASTOBECOMESUBJFCTTOiHE . . i•�� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIFISHOULOBECOML ' ; INSPECTIONFEE ___._..._..__._..—..._.__..__.__--_._.__.......______...__�� SU&IECTTOTHEWOHKERS'COMPENSATIONPROWSIONSOFSECTION37000FfHELA�OR �SSUANCE ':�.-�j. CADE. SHA FORTHWITMCOMPLYWITiTFpSf�ROVISIO , '� _.....-. .---"'� ;,;�' [/�'��J � -:'..p�� DATE: � y APPLICANT. ___7 "' _ < SMIP --- -.---- --. �.;:�. ENERGY P/C �, WAflNINQ ILURETOSECUHEWORKERS'CDMVF.NSATIONCOVLRAGEISUN FUL.ANDSHAIL ' '�".':�y��. SU0.IECTANEMPLOYERTOCRIMINALPENALTIE3ANDCIVILFINF.SUPTOONEHUNDREDTHOU3AND ENERGYPERMIT � -�.e�y ! DOLLARS(f10o.0ao),INAODITIONTOTNECOSTOFCOMPENSATION,DAMAGESFSPflOVIDEDFORIN �� ".J� SECTION 3]oe OFTHE LABOR CO�E,INTEREST,allo A7roaNers FEEs. RETENTION FEE: . ���J �;...W, _.__._...._..._._— . ��. �� CONSTRUCTIONLENDINGAGENCY PHE-ALTFEE: ___________ ___.____.___ O' `'���� IHEREBVAFFIRMUNDENP[NPL7VOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGqGENCY _ ___,__,___ ___ � FOflTHE PERFOFMANCE OF THE WORK FOR WHICH THIS DERIAIT IS ISSUED(SEC.3ae'I,CIV.C.). ---- Z ��. W. . ..—..—_""'_—_ LENOER'S NAME ___ .._._..__- ___ H' LENDER'SADDRE55_ _ -----�-- ��'�' ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATE7HRTTHCABOVEINFORMATIONISCOFRECL TOTALFEES � W' 1 AGREE TO COMPLV WITH ALL CIN PND COUNTY ORDINANCES AN�STATE LAWS REIATING TO BUILDING � CONSTRUCTKKJ,ANOHEREBVAUTFIOFIZEREPRESENTATIVESOFTHISCWNNTOENTERUPONTHE .�.Z ABOVE•MENTIONEOPROPERTYFOflINSPECTIONPUftPOSES. COMMENTS ' _.___._—.___..--. �t�,. \"7t �."p j� �2��l.• ----� - -- • e-�r•, �..�,a=o- , , Q. DERMITTEENAMEP' M) _—_ - ' �---- � � l� .�,� . �� . . 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