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HomeMy WebLinkAbout15307 (19) .. � -- c� �__ CITY OF DIAMOND BAR �---�`- DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES �� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��'���'� � BUII.DING PERMIT APPLICATION FIRMLY � JOBSITE / (�,, APPLICATION�� �(' Jr'Z� PERMIT P!C o ADDRESS�1_ � `F' �C'' ��L�� DATE 'Z'V'� NUMBER�.����#_ c� ISSUE TYPE OCC APN _ OT_ TRACT_. _ DATE CONST. GROUP p OWNER ��� '�U ZONING SETBACKS " ADDRESS � W �'` '° FRONT RW ❑ � CITY_ ZIP���TEL.�� � REAR ❑ _ APPLICANT TEL. SIDE/SIQE STREET RW O � CONTRACTOR e /cy,,�y SIDE _ Cl___ Q A�DRE _, � � !K1 U�'\/ --*-- t t o �3� � CITY iC'_ b1- n/� ZIP TEL. ���.1'�"���ZS PROPOSED USE _2.� �• w ARCH/ENG/ f(s/ � ,r' � �ESIGNER NO.DWEL. NO. NO. a ADDAE55 UNITS STORIES _ BEDROOMS � CITY ZIP_, TEL. _ y — DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION N OOWNER-BUILDEFl DECLARATION SFR/ADD/REM 0 1 HERE6V AFFIHM U�17EF PENALTV OF PERIURY THAT I AM EXEMGT FHOM 1NE CONTRACTORS LI� (a`a�dJB/CdIpOfl W CENSEIAWFORTHEFOLLAWM6flFASUN(SEC.7W1.58USiNE55ANDPHOFESSION9CODE:ANYCITYOH (f� _ U COUNryWHICHREWIRE&APFAAIITTOCON5TPUCT,ALTEN,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W P8fi0/�ed( WNHE,PHpR TO ITS ISSUMICE.RL50 RE�UIflES TME APPLICANT FOP SUGH PEflMIT TO FILE A SIGNED W STATEMENT THA7 HE OR SHE IS LICENSED FURSUAN7 70 THE PROVISIONS OF THE GONTRACTOR6 I.I- � � CENSE LAW(CHAMER 9(COMMENCIND WITH SECTIDN 7000)OF DIVISION 3 OF THE BUSINF.SS FN�PRO- PODI/Spa FESSpNSCO�E)ORTNATMEORSHEISEXEMPTTHEREFROMANDTHFBASISFOR7HEALlEGEDEXEMP- C7 U TION.ANVVIOUTIONOFSECTION7031.5BVANYAPPLICANTFORAGERMITSU&lECT3iH[APPLICANTTO z R8-ROOf � AqVILVENALTYOFNOTMORETHM1NFIVEHUNDREDDOLLARS(S5ao).7: � ❑I,ASOYMEROFTHEPROPERTV,ORUYEMPLOYEF.SWITNWAGESASTHfiIRSOLECOMPENSATION, ❑ COmrtl8fCi2I ' NALL 00 7HE WORK,M10 THE STRUC7UFE IS NOT IfJTENOED OR OFFERED FOR SALE(SEC.7044,BU51• ,�I NESS AN�PpOFESSIONS CODE:TNE CONTMCYORS LICENSE LAW 60E5 NOT APPI.Y TO AN OWNER OF � VROPERT'NM1IOBUIL0.SORIMPHOVESTHEREON,AN�WFiODOE55UCHWORKHIMSELFORHCRSELFOF � Q THROUGHNISORHEROWNEMPLOYEES,PRDVIDEDTHATSUCHIMPROVEMENI'SARENOTINTENOE�OA m O, OFFEREDWR5N.EIF,{IOW6yEFLTHEBUIL0INGORIMPROVEMENTISSOLDWITHINONEVEAflOFCOMPLE- __ Z TION.THE OYYfdER-BUILDER WILL MAVE TNE BUNDEN OF PROVING TMAT HE OR SHE DID NOT E3111LD OR � IMPflOVEwRTHEPUflPOSEOFSALE�. W ❑I,iISOWkEflOFTHEPROPERiY.M1EXCLUSIVCLYfANTRRGTINGWIThiIICENSEDCONTRACTOFS -- • � � l5 Q[ TO CONSTflUCTTHE PR0.IECT(SEC.to1a,6USINESS AND PfiOFESSIONS CAUE:iHE CONTRACTOPS LI- VtIt1B�i0� .,,..__ _.__ADJ.AREA_ W CENSE LAW OOES NOTAPPLV TO AN OWNER OF A PHOPERTY WH00t11LD5 OR IMPROVES TMEREON,AN9 FNTqCONTMCT5FOR5UCHPRWFC7SWIh1A�YTflACTDR�S)LICENSFDPURSUPMTOTHECONTRAG QUANTITY DESGRIPTION FEE Y TORS LICENSE LAW.). ¢ J O O i AM E%EMPTI/NDER 3E,C.___..__—._—_...._._—___8.&P.C.FOR T415 REASON a � _'_—_"'_"___ __.'_--' U � u' �ATE_—" OWNEfl___'_'""""___—_""__'_— ~ M � � w — I F LICENSED CONTFiACTORS DECLARATfON �j _ � � IHEqEBVAFFIRMUNOEPPENALTYOFPEflJI1FYTHATIAMLICENSEDUNDFRPitOV15:O�5CFCHAPTER � p„ B(COPtMENCINOW�TFISECTION7aao)OFDIV�SION:fOFTHEql15MESSANUPHOFESSIONSCODE,AND Z __ _ X MYUCENSEISINFULLFORCEANUEFFECY ' j 61J . j(�� m +I � UCENSECLA55 •�I _LIC.NO._._�����,,�`/� � s � I� V DATE.��'�`?7�"'r3 e GONTRACTOR ./��___ _G�_S!._���/ a �� ! W _--- d� WORKERS'COMPENSATION DECLARATION J�•'�j i d � � ��� V U � 1 HEHEBY AFFIRM UN�ER PENALTY OF PERIURY ONE OFTHE FOLLOWING DECLARATIO S: � Q '_ ' � ,_.IMAVEANOWILLAUINiAINkCERIIFICATEOFCONSENTTOSELF�INSl1REFORWORKEfiS' � � GOMPENSATION.AS PROVIDF.O BY SECTION 370a OF 7HE IABOfl CODE,FOH THE PERfbRMANCF: W OF THE WURN FOR WFIICH THIS PERMIT IS ISSUEO. � � 0 W __�HAVEANDWILLMAINTAINWOFiKEAS'COUPENSATIONINSURFNCE,ASREOLIREUBYSECTION � � '.� Q 37000FTHELAEORWDE,FORTHEPERFORMANCEOFTHE'rY ?KfOfiWlilCh{TIiISPEfiM117i5 � ISSUED.I.SY WORKEP.S' N INSUR CARRIE 'D POLICV NUAAAE47 ANE: � CONSTRUCTION � "—-' —__ � / �w� . � PLAN REVIEW ------------ ------- .i�. � CARRIEH.____=_�`.f�'�— ... Z POLICYNUTABER___-F D.���_�... :-.-._--.-. ELECTRIC _.__...._....- _,----._-- ��--� ° :�---- � 6 -• ,( ' � (M6SE(:fIONNE�KJTBENM%FIFDOFiFEPEftAtlTlSf(1HONF.IU�OREDIX71.4NiS�700)ORLE35} PLUMBING .__.___......_ . . .�._.—.__. Z I C[RTIFV TNAT IN THE PERFORMAKCE Of THE WURK FOP WNICH THIS PEHMIT IS ISSl1FD.I MECHANICAL _._____.___ ______._., _.._.__._--_.___. (,�j SHPLL NOT EMPL9V qIVY VF.R50N IN M1Y MFYNeFl 50A5 TO OECOME SU�JECT TO THE �� �, � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREF.THATIFISHOULUOECOMf: INSPECTIONFEE _.��,�.,_° � 3� ' ______� � 5�81ECTTOTH[WOP%EHS'COMPENSA710NPROVI SOfSEGTlO� 7ooUF1H"LA80R � ISSUANCE •••.,,, ,� � � LO E,1 S ALL FORTMWITH COMPLY Wlhi TH�SE ISIqNS. _ „ �' ��_;� --��----�- --- � � r-o�. �-�� SMIP "_�`S�' ����T�C}I�C)�.f�x, `�� p DATE:,_....__ APPLICANT _.._'_. _ 'CIZ __ __._ �cx--l- - W ENERGY P/C ���-���T�_�t 'J WAflNINO:FAILUflE TO SECUR[�"10RKER5'COMPENSATION COVERAGE IS 11NtAWFUI.,ANO SHALL BF LL SUBJECTANEMPLOYFRT'OCRIIdINALPLNALTIESANOL'IVILFNESUPTOONEHUNDRFDTIfOUSAND ENERGYPERMIT _.___..._. �1'S�_ DOlUlRS(i100.0001,�N ADDITION TOTHE COST OF CAMPENSATION,�AMAGES AS PROVIDED FOR IN --- . � SF.CilON370BOFTHELABORQ7�E,INTEREST,ANDATTORNEN5FEE5. RETENTIONFEE: .........'_—""_'_ '...."_--'___"__ d CONSTRUCTION LENDING AGENCY PRE-ALT FEE; �" -__�_--- �----- --- :, : � I HFREBY AFFIHM UNDER P[NALTY OF PERJURV THAT THERE IS ACONSTf7UCTION LEN�ING FGENCY �� FOfl THE PERWRMNiCE OF 7HE WOHK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). �� ����� �� ���� �� Z '_"'_'___'_"_ "_'_"_ W � LEN�EH'SNAME."'_'""__—_'—_—'——__.___'__"__""""'_—_—__ "�. F- LENOEH'SADDRES9 �—�—�--- �,-: , J� � ICERTIFYT11h'fIHAVEREAUTNISAPPIICATIDNAN�STATF7'HATTHEA90VCINFOfiMATIONISCARRECT. TOTAL FEES �:/ �+ � (/ �� � IAGfl[ETOWMPLVWITHlLL.LCITYANDCOUNTYOFDINANCESANDSTATELAWSREIATINGTOBUILDING n� � J � CANSTRUCTION,AND��EREOY AUTHOFlI7E RCFfl[SLNTATIVF.S Of 7FIIS COUN7Y TO ENTEH UPON 711E // G/ z ABOVE�MENTIONED, �EHTYFORI-SPECT�NPUpP ses. GOMMEN7S- ._-` ��� �� L _ _� _ � % � '-- -' - � � — - -- m PERMRTEE NAME(P T', —_'__'____'_- a �� 1 t5'� -----�--- ; � ... . - ---- - -- ----- - �- � SIGNATUNEOFPEL7MITfE[ ATE �� � RECPT.N0. � PAID BY _,_. 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