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HomeMy WebLinkAbout12161 J, � CITY OF DIAMOND BAR - "�'�' DEPtLRTMENT OF COMMUNITY&DEVELOPMENT SERVICES , �i ��; 21660 E.Copley Drive Suite 190 T (909)860-3195 Fax(909)861-3117 PRESS 'A�' BUILDING PERMIT APPLICATION FIRMLY o DDRIESS �-1`f'Sf'�rO� S F�}�j ��� DATE CATION � �� NUMBE���� �� #!C � ISSUE TYPE OCC r APN LOT TRACT DATE CONST. GROUP p OWNER y ��� ADDRESS , ZONING SETBACKS � � r � FRONT RW U _ CITY ZIP TEL.-�/�'• f'� REAR n APPLI ANT ' TEL.f � SIDE/SIDE STREET RW Ll � CONTRACTOR ° SIDE ❑___ o ADDRESS ' ) - CITY h Z P� TEL. . � PROPOSED USE a3 i� � w ARC N � ��� � z DESIGNER a ADDRESS NO.DWEL. N `' NO. {� N UNITS STORIES BEDROOMS � �. CITY ZIP TEL. v� DESCRIPTION SQ.FC FACTOR PSF ADJ.AREANALUA710N p� OWNER-BUILDER DECLARATION SFRlADDJREM O p I HEREBY AFFlRM UNDEfl PENILLIY OF PERJURY THAT 1 AM EXEMPT FRINA 7HE CONTFAC70ftS LI� G8(2ge/C2�Ort W CENSEUWFOHTtIEFOLLOWINGREASON(SEC.7031.58USINESSANDPilOFES510NSCODE:ANYCITYOfl (n . CJ. COUNTVNMICHREOUINESAPEH1AtTTOCONS7PUCT,AL7ER,IMGROVE,�EMOLISH,ORREPAIRANYSTRUG W Pa�iO/DBCk W TURE,PHIOR TO IT6 I6SUANCE,ALSO REOUIRE6 THE APPLICANT FOR SUCH PERMIT TO FI�E A SI�NE� W STATEMENT THqT HE Ofl SME IS IICEN5E0 PURSUMIT 70 THE PROVISIONS OF THE CANTMCTORS LI� � CENSE lAW(CHAPTEH B(COMMENCINO WITH SECTION 700D)OF DIVISIDN 30F THE BUSINE55 ANO PRO� � POOVSDB � F�SpNSCOOE)ORTHATHEORSHEISEXEMPTTHERFFR0IAANDTNEBASISFORTHEALLEGEDE%EMP- (� .TION.ANYVIOIATpNOF5ECT10N7v31.58YANYAPPLICAN7FOfiAPERMITSUNECT57HEAPPUCANTTO Z Re-Roof � ACMLPENALTYOFNOTMORETHANFNEHUNDFlEDDOLURSli500I.): ,� ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPIOYEESWI7HWACESASTHEIRSOIECOMOENSATION, O Comm9fCial ' WILL 00 THE WORK AND TME STRUCTUHE IS fiOT iN7EN�ED OR OFFERED FOR SALE(SEC.7044,BU51• J : N NESE AND PROFESSIONS CODE THE CONTRACTORS LICEN3E LAW DOES NOTAPPLV TO AN OWNEH OF �� � OROPERiYW/10BUILD50NIAiPROVESTNENEON,ANDWHDOOFSSUCHWOHKHIMSELFORHERSELFOq Q TNRIXI4HHISORHEROVINEMPtAYEES,PHOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m 'Q ,OFFEREDiORSALE.IF,HOWEVER11iEBUILDINGORIMPHOVEMENTISbOLDWITHINONEYEAROFCON%.E .Z 'TION.THE OWNEH�BUR�ER WILL HAVE THE BUROF.N OF PROVMG THAT HE OR SNE�ID NOT BUILD OR w MIPROVE FORTHE PURPOSE OF SALEJ. ❑I,AS ONMEROF THE PROPERiV,AM EXCLUSNELY CONTRhCTING WfTH LICENSED CON7RACTOflS �� TO CONSTRUCT TME PROJECT(SEC.7U�6,B1151NF.SS ANO PHOFESSIONS CO�E:THE CONTRACTORS LI� V8IU8fI0f1 ADJ.AREA..,,__.__ ___ CEN6E lAW DOES N07APPLV TO AN ONRJEH OF A PROPERTY NA10 BUILOS OR IMPROVES THEf1EON.AN� ���� NRIDCONTMCi5FOR5UCMPROJEC7SYYITMACONTRACTOR(S)LICENSEDPUR3UANTTOTNECOMRAG QUANTITY �ESCRIPTION FEE �' T00.S LICENSE UW.�. U IMI EXEMPT UNDER SEG___,_ __B.3 P.G FORTHIS REASON � Q O U � ------------------ � V" DATE OWNER � �'" � � W �, LICENSED CONTRACTORS DECLl+RATION , W �;��. I HEREBV AFFIRM UNDER PENA�N OF PE0.1l1RY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � N� , ��'� B(COMMENCiNO WITH SECTKKJ 70W)Of�IVISION a OF YHE Bl1SINES6AND PROFESS!ONS CADE,AND Z X A1Y UCENSE IS IN NLL FORCE PND EFFECT. (yJ; m .�� LICENSE CLAS �'�LIC.NO. '� � '} � j � J .w �ATE CONTRACTOR�,m9� ..,_JI,�. �. '�n. ��°i �� -��� WORKEftS'COMPENSATION DECLARATION Q � V �' I HEREBY qFFINW UN�EH PEWLLTY OF PERJURY ONEOF THE F9LLOWING�EGLARATIONS: '� Z O�. IHAYEANDWILLMAINTAINACEqTIFICATEOFCONSF:NTTOSEIFdNSUREFORWOHKFR3' _ �� COAIPENSATION,ASPROVIDEDBVSECTION37o00FTHELABORCODE,FORTHEPEflFORMANCE ' W OF THE WORN FOR WHICH THIS PF.flMIT IS ISSUED. � �Q, _ � _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIQNINSUqANCE,ASPEQUIREDUVSfCTION ry �� �Q 37011 OF TMF.1A90R CO�E,FOR iHE PERWRMANCE OF THE WORN FOR WHICH THIS PF.RMIT IS /1/ ISSl1ED.MY WORKERS'COM ENSATION INS RANC CARRIER PND PDLICV N11M8[R ARE: CONSTRUCTION _��"i'V_P � �..�.j��, cARRIER----� PLAN REVIEW _ --_ ----- �0� POIICVNUMBEH_�P�"/�+w2 ELECTRIC ,Z:., — —....'_..'_....___ _..._ Q _"'_'_ �d� (iHI55Ef.'iIONNE�N0TBE00ApLElIDOFiHEPEFiA�O71SFORONEHU14lREDNLLA0.S(5100)OqLESSa PWMBING ___._ _'_'____ :�Z I CERTIFYTHAT IN 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL ____.___ ;�(,'}: SHPLLNOTEMPLOVANYPERSONINANVMANNERSOAST08ECOMESUBJECTTOTIIE '(/j" WORKERS'GOMPENSATKKJLAWSOFCFLIFORNIA,ANUAGHEETHATIfISHl7UlOBECOME INSPECTIONFEE ___.___ _____.__ -�i� •= SU&IECTTOTHEWURNERS'COMPENSATIONPROVISIONSOFSECTION37000F7MELABOR ` ��l//�� isioras. ISSUANCE � > ------------- —�---'-- O; ��W� WApN.INp�AIIURETOSECUflEWORK'ERS'COMPENSATIONCO ' � „ coo . , . ---- SMIP __..__......------- '� "—�' VEflAGEISUNIAWFU,ANOSHAlLOE ENERGYP/C ____._.________ J� SU&IECTANEMPLOYERTOCRIMINALPENALTtESANDCIVI�fINESUPTOONEHUNDRED7HOUSAND ��� OOLLARS(S�Du.000j.MAD01TON70THECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENERGYPERMIT _________....______ �J� SECTION37oeOFTHELABORCODE.INTEREST,ANDATTORNEI"SFEES. RETENTIONFEE: �` -- ���d��. CONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: _ ,��;� I HEREBYAFFIRM UNDER PF.NALTYOF PERJURY THAT TMEflE IS A CONSTRUCTION LENDING AGENCY _____ _ _ _ FOR iHE PER(-0RMANCE OF THE WORK WR WHICH 7HI5 PERMIT IS ISSUE�(SEC.3a97,CIV.Q�. Z -�W:. —"--- - LEN�ER'S NAME ._____ — '�, '_'_' '_"'_ ..1—� LENDEfl'SADDRESS_' _""'___..."__'_'_'_— �-�� ICERTIFVTiATIXAVEREADTHISAPPLICATIONAND3TATETHATTHEABOVEINFORMATIONISCORRECT. 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