HomeMy WebLinkAbout10735 (5) CITY OF DIAMOND BAR � � COMMUNITY DEVELOPMENT DEPARTMENT ��; 21660 E.Copley Drive Sui[e 190 - PRESS }f ��'H�'�� BUILDING PERMIT APPLICATION FIRMLY � � JOBSITE �, �'` ��/i � rJ� �d�„` APPLICATION !� �� ��NU BER �����#/C o ADDRESS 1�� DATE �✓ $ ISSUE TYPE OCC APN LOT�-7– TRACT DATE CONST. GROUP °C OWNER -'{''��'� r+`�� �'�'�- ZONING SETBACKS o ADDRESS l r �' ��� �' FRONT RW L_1 o ��--�---�� � � CITY ZIP TEL. REAR I� APPLICANT TEL. SIDEISIDE STREET RW ❑ # a CONTRACTOR SIDE ❑ � � ADDRESS PROPOSED USE �--~k-'����"��--'"'�"' �r�� � CITY ZIP TEL. �� r.. �• ,.�_. � w ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. � � ADDRESS 11NITS STORtES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATIOPI � � OWNER•BI:ILDER DECIARATION SFR/ADD/REM � O p I HERC-BV AFFiFlAI UNDEN PENALTV OF PERJURY iHA7 1 AM EXEMPT FROM THE CONTFiACTORS LI� Gef899/CefpOft I,IJ CENSELAWFORTHEFOLLOWINGREASON�SEC.7031.SBUSINE55ANDPROFESSIONSCODE:ANYqTVOR (n { U CUUNTYWHICHREOUIflESAPEFMI7TOCONSTRUC7,PLTEfl,IMPROYE,DEMOLISH,ORREPAIRANY57RUG W pafi0/DBCk D �' NRE,PRIOFi TO ITS ISSUANCE,ALSO REQl11HE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll- CENSE LAW(CHAPTEfl 9(COMMENCING WITM SECTION laoo)OF DIVISION 30F THE BUSINE55lJJD PRO� � POOVSPB � U FESSIONSCODE)ORTHA7HEONSHEISEXEMPTTHEAEFHOMANDTHEBASISFOHTHE0.LLECEDEXEMP- TION.ANVVIOUTIONOFSECTION7031.6BVANVAPPLICANTFOFAPERMI7SU&IECTSTHEAPPLICANTTO z Re-Roaf F ApVILPENALTY OF NOT MORE 7HAN FIVE HUNDRED DOLIAFS(SSOD),): j CJI,ASOWNEHOFTHEPHOPERN.ORMYEMPLDYEE&WRXWAGESASTHEIfiSOLECOMPENSAi;ON, . 0 Commerciai ` Z� WILI DO TNE WORK,AND THE STFUCTURE IS NOT INTENDEO OR OFfEpED FOR SALE(5EC.7066,BU51• J NESS AND PflOFE5510N5 CADE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF � PRODER7V OBUILDSORIMPROVESTHEREON,/N�WHODDESSUCHWORKHIMSELFORHERSELFOR m � � THflWOHH15 RNEROWNEMPLOYEES,PROVIDED7NATSl:CNIlAPqOVEA1ENT5AflENOTINTENDE00fl W OFFFAEDFOH PLE.IF,HOWEVER.THEBUILOINGOflN1PROVEMENTISSOIDWITHINONEVEANOFCOMPLE- �' TION.THE OWkER�BUILDER WILL HhVE TXE BURDEN OF PROVIN6 7HAT HE OF SHE DID NOT BUIlO OR Z� IM O FORTHEPURP'OSEOFSALE�. _� IASOWNEflOFTHEPflOPEHTV,AMEXCLUSIVELVCONTRACTINGWITMLICENSFACONTRACTOHS � TO NSTflUCT TME PHQIECT(SEC.70/6,BUSINE55 AND PROFESSIONS CODE:THE WNTRACTORS LI� V8IU8IIOf1 ADJ.AREA �' CE SELAWDOESNOTAPPLVTOANOWNEPOFAPROPERTYWHOBUILDSORIMPROVESIHEREIXi,AND � � � YMOCONTMCTSFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPURSUPNTTOTNECONTRRG pUANTITY DESCRIP710N FEE Y TDRSLICENSEIAW.j. •,,�, O B.S P.0 FOR THIS REASON a � ��"�1 5 2.�� ""�, l)1 AM EXF.MM UN�ER SEC.___..__.._ �/. � � - .., F '� �� �°dl/6 DA7E �� ,__ OWNER. ..•�`—'-- U �4as� W � LICENSE�CONTRACTOf75 DECLARATION —r W 1 HEFEBVAfFIflM UNDER PENALTY OF PEHJURY THAT IAM LICENSED UNOER PROVISIONS OFCHAPTER � t � ! d B(COMMENCING wITH SECTION 7000)OF DIVISION a OF iHE BUSINESS AND PROFESSIONS CODE.AND Z X MYLIGENSEISINFULLFOflCEANDEFFECT. . m I � � � LICENSE CU155___ lIG NO. _ -- , � H U DATE_ COMRACTDR ' 0- W :a � WORKERS COMPENSATION DECLAHATION � Q . f4 � V P� � IHEHEBYAFFIRMUNDFRPENALTYOFPERJUflVONEOFTHEFO�LOWINOOECLAflATqNS: Z {� Q #� Z _IIIAV[ANDWILLMAINTAINACERT�FlCATEOFCONS[NTTOSELFINSUFEFORWORKERS' S 4 �pMPENSATION,AS PROVIDED BV SECTION 370D OF THE 1A80q CODE,FOR THE PEFFORMANCE U � a OF THE WORK FOR WHICH TiIS PEHMIT IS ISSUED. � � � � _IHAVEAN�WILLMAINTAINWORKEPS'COMPENSATIONINSURANCE,ASREOl11REDBYSECTION Q 37000FTHELABORCODE.FORThIEPEflFORMANCEOFTHEWOflKFORWHICHTHI3PERAUTiS � ISBUED.MV WORKEPS'COMPENSATION INSUHANCE CARRIEfl AND POLICV NUMBER AflE: CONSTRUCTION jc,wniEa---.- .--- --....---- PIANREVIEW ------- --�,�� � ELECTRI � v � `r Z POLICY NIJMBER_. _ Q . � pH65ECTqNNE�N0T0[ODMPLETFD�FTYEPEPl-MfISFOHONEMN�DRED00WA5(510U�OFLESS� PLUMBING _ w MECHANICAL . z I CEHTIFY THAT W THL PERFORMANCE OF THE WOflK FOFi WMICH THIS PERMIT IS I55UED,I — --- ('} SHALLNOTEMPLOVANYPERSONINANYMANNERSOAST08ECOMESUBJECTTOTHE � WORKERS'GOMPENSATION LAWS OF CALIFOPNIA,AN�AGREE THAT IF I SI-tt�ULU BLCOME INSPECTION FEE � __ Sl1BJECT 70 THE WORKEFlS'COMPENSATION PftOVI5lON5 OF SECTION 3700 OF THE LABOH `; ",�w� � CODE,ISHALLFORTHWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCr,+ __ '° � SMIP � p DATE:_ APPLICANT: _ _—_ --'--- .. ' � ENERGY P/C __ WARNING:FAILURE TO SECUiiE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AN�SHALlBE �.,�, -� � � SUBJECTANEMPIOYEfiTOCRIMINALPENAL7IE&PNOCIVILFINESUPTOONEHUNDRED7NOUSAN� ENERGYPERMIT __ � � IDOLURS(S10D.0001.IN ADOITION TO THE C0570F COMPENSATION,DAMAGES AB PHOVIDED FOft IN ' I � SECTION 3708 OF THELA90R CODE,INTEFEST,ANO AiTORNEY'S FEES. RETENTION FEE: ___ I d CONSTRUCTION LENDING AGENCY PRE•ALT FEE: p p� q B I �� 1 HEN�YAFFIRM 11NDEfl PENALTY OF PEfiJURY THAT TMERE IS A CONSTqUCTION LENDING AGENCY _ A°�IJ I �- 7{�ld/ . FORTHE PERFORMANCE OF THE WORK FOR WHICN THIS PEHMIT IS ISSUED(SEC.3097.CIV.C.�. ��'� —rf'-T.�.� W i ,� LENDER'S NAME __._ -- __ i F� IENDERSADORE55_ — S�O ¢ ICENTIFYTHATIHRVEREADTHISAPPUCATIONANDSTATETMPTTHEABOVEINFORMPTIONISCORqECT. TOTAL FEES �iO l � �� W IAOREETOCOMPLVVATHAILCITYANDCOUNNOROINANCE5ANO5TATElAWSR LATINGTOBUILOING `�' � CANSTFUCTION,ANDHEHEBVAUTHORREflEPRESENTATIVESOFTHISCWNTYT ENTEqUPONTHE � Z A80VE�MENTIONEDPROPEHTYFORINSPECTIONPURPOSES. 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