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HomeMy WebLinkAbout12604 (11) _ �„`_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� . 21660 E.Copley Drive Suite 190 ✓ (909)86Q3195 Fax(909)861-3117 PRESS �'��'� BUILDING PERMIT APPLICATION FIRMLY � D RIESS -�"j APPLICATION � ��"�.��� NUMB R " D #,C DATE � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER. � �- VLL��L��/� s p ADDRESS�I���� �_SDdIInl,F ! ZONING SETBACKS w FRONT _ RW L' � CITY�/,��i���� ZIP� TEL � - ?' � REAR ❑ ---_ APPLICANT TEL. SIDE/SIDE STREET RW CJ aa CONTRACTOR SIDE _ �j_.__ ADDRESS o CIIY ZIP � TEL� -1 - PROPOSED� 6�.�/YI191��(,L/�8� GJf��fd[/-c �aVg!",��L_ ow ARCWENG/ 3.�� L�%�-1l,L�d�'tiF17� - e~ �i �. i"i W DESIGNER NO.DWEL. NO. NO. a ADDRESS " ' ' � UNITS_ STORIES '__ ' ''' BEDROOMS � CITY_ ZIP TEL. u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEA DECLARATION SFR/ADD/REM O 1 HEREBY AFFlRM UNDEA PENAl7Y OF PERJIIRY THAT I AM EXEMPT FAOM THE CONTflACTORS LI• G2f�1(JBJCBfPOfi � � W CENSEUWFORTNEFOLLOWINGREASON(SEC.7031.58U51NE55PNDPflOFE5510N5CADE:ANVCITYOR U COU,yTYWHiCHqEOUIRESAPERMITTOCONSTFUCT,ALTER,IMPROVE,DEMOLISH,ORREDAIRANYSTRUC W NRE,PRIOA TO 1T9 ISSUANCE,-ALSO REQl11RES 1HE APPLICANT FOR SUCH PERMIT TO FILE A 916NE� w Patio/�eck � STATEMEM TMAT HE OR SHE IS UCENSED WRSUM7T TO THE PROVISION3 OF T}1E CONTRACTORS LI� � CENSE LAW(CHAPTEH e(COMMENCING WITH SECTION�000)OF DIVISION 9 OF THE BUSINESSAND PRO� P001/SPfl � FESSpNSCOD�OR7HATHEORSHEISE%EMPT1'kIEREFROMAN�'fNE8A515FORTHEALLEGEDEXEMP- � V TION.ANYVKKATIONOFSECTIO:i7031.5BYANYAPPIICNNTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roo( r A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(f5oo).)� '� ❑�.ASOWNEROFTNEPROPERTY,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, COf11111BfC191 �� WILL�O TME WOFi1C,AND THE Sl'RUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7044,9U51� �J � NESS 0.ND PROFESSIONS COUE:TME CONTRFCTORS LICENS[LAW OOES NO7RPPLV 70 AN OWNEH OP � DpOPERTY NAiOBUILD50R IMPROYES THEREON,AND N710 DOES SUCN WORKHIMSELF OH HERSELF Ofl L� iHROUGHH190RHEROWNEMPLOYEES,PROViDEDTHATSUCHIMF'NOYEMENTSARENOTINTENDE�OF m QOFFEREDWRSALE.IF,HOWEYEfi,iMEBUILDINGORIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE� Z TION,THE OWNER-9UILDER WILL 11AYE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE). ❑I,AS OWNEROF TH[PROPEHTY,RM EXCLUSIVELY CAN7MC71NG WITH UCENSED CANTRACTOflS �� TO CONSTfiUC77HE PROJEC7(SEC.70�0,BUSINESS AND PROFESSIONS OODE:THE CON7RAC70RS LI. 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LIC.NO.� ��V j �UDATE � �. � CONTRACTOR�f�[�,� _ J W � � .—_ � WORKERS'COMPENSATION DECLARATiON `p�]-�4e' Q �V / � IHENEBYAFFIRMUNOEflPENALT/OFPEFiiURYONEOFTHEFOLLAWING�ECLARATIOt7S: Z � _IHAVEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUflEFORWORKEPS' _ — COMPENSATION,ASPFOVIOEDBY5[CTION37600FTHELABORCOD[,FORTHEPFRFORMANC'e �U OF THF.WOflK FOfl WHICH THIS PERMIT IS ISSUED. � � W _I HAVE AND WILL MAIHTAIN WORKEflS'COMPENSATION INSURANCE,AS REOIJIPED BV S�CTI04 ' O 370GOFTHELABORCADE.FOHTHEPERFOqMANCEDFiHFWORKFDRWMICHTHISPERMITIS ' .� ISSUED.MY W�OR�NE,R,,S,'C,�OAIPENSATIO I URANCE CARRIEN AND POLICY NIJMBEfl ARE�, CONSTRUCTION ,_,__,.,,_.________...__ �__�� , � CARRIEH��� ---- — - - cl PLANREVIEW -----....._........_.. ......--------__.---� . � Z POLICYNUMBEH �' � � ELECTRIC '_."....._....._'—_'_."'_ ._....._..—_ _'.___'__ 4 �R : . � (fH55EC110NNE�NOTBEC01�FLk7EDOFTIF.PER1ATlSFOHONEMJHKIEDDOLIMS(S1�o)OHlE55� PLUMBING _'._....,....__—_""" W .Z i CERTIFV THAT INTHE PERFORMANCE OF THE WOflK FOR WHICH TFIIS PERMIT IS ISSUE�,I MECHANICAL � _,__.__„_,___.. '�(j SMALLNOTEMPLOYANYPERSONI4ANYMANNERSOASTOBECOMESUBJECTTOTHE �,(n WORKERS'COMPENSFTKKJ IAWS UF CALIFORNIA,AND AGflE[TMAT IF I SHOt1L0 BECOAIE INSPECTION FEE � • —"".'_'_.—..... �' SUBJECT TO THE WOflNEflS'COMP[NSA710N PROVISIONS OF SECiION 3700 DF TH[LABOR � � CO�E,ISHALLFORTMWITHCOMPIVWITHTHOSEPROVISiONS. ISSUANCE � � /� j�(y�/ (� (� _.._._—.... � L �"V SMIP --{�.k3_f_ O��e��id ---- , . . p- OATE: 'I APPLICANT: ._'_ _ ' _._--._..___'....._,.._._. � �"'� WARNING�FAIWflETOSECUPEWORKERS'COMPENSATIONCOVERAGEISIJNLAWfUL,ANDSFSALLBE ENERGYP/C'�e7 �p�� ,,,________,_..._._........__��p ____________ -� SUBJECTM'EMPLOYERTOCRIMWALPEN/LTIESANDCIVILFINFfiUPTOONEHUNDRF.OTHOl15AND ENERGYPERrviy,,gT�V1.DIAMONDBl1li � DOLUIRS�$1w,o0D),INA�DITIONTOTHECOSTOFCOMPENSATIO�,DAMAGESFSPROVIDEDPORIN Tr 7�7�� �^[', -.------_._—_— _¢ SECTION37oBOFTHELA90RCODE.INTEREST,ANOATTORNEV'SFEES. 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