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HomeMy WebLinkAbout16629 (17) _ -- __ — __ - ----- - - - _. �-� CITY OF DIAMOND BAR ��' � ��� � -- --��``' --- DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES.�.----'"~`��'� I I � _ 4,� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 P, ES$ '"��ry'�� BUILDING FER1dIIT APPLICATION � �p�j I R M LY o� JOBSITE /L' f� +� /'�. ��,,,,._ APPLICATION �...�11 � a�"il NUMB R • #����� ADDRESS_ �`��� DATE v'�..��°"� � , � ISSUE TYPE OCC APN LOT I TRACT DATE CONST. GROUP p OWNER �— I�dl�a o ADDRESS I� � 20NING SETBACKS z CITY Z�p TE�, FRONT RW ❑ o APPLICAN7 TEL. S DE/SIDE STREET RW ❑ z Q CONTRACTO Sr (g� SIDE ❑ � ADD S � CITY ZIF� l�_ TEL. PROPOSED USE w ARCH/ENGL �� z' DESIGNER a ADD SS L NO.DWEL. NO. NO. UNITS STORIES BEDROOMS � CI '� ZI TEI� v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � O NER-BUILDER DECLARATION SFR/ADDlREM O p I HEfiEBY AFFIRM UNDER PE pl:TY OF PEflJURY THAT I AM EXEMP7 FROM THE CONTRACTORS LI- G8f892/C8l�OfI W� CENSELAWFORTHEFOLIOWING EASON(SEC.7o37.5BU51NE5SANDPROPESSIONSCOOE:ANYCITYOft (n U � COUNTYWHICHREWIRESAPERM�TTOCONSTRUCT,ALTER,IMPfiOVE,OEMOLISH,ORREPAIRANYSTRUC- W PatiO/DeCk W �TUflE,PRIOH TO ITS ISSUANCE,A 50 RE�UIRES,THE APPLICANT FOR S�CH PERMIT TO FlLE A SIGNED W STATEM�NT THAT 19E OR SHE IS ICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACiORS LI- ���' ,CENSE LAW(CHAPTER 9(COMME qNG WITH SECTION 7ooa)OF DIVISION 3 OF THE BUSWESS AND PRO- �'1' POOUSPe 0' 'FESSIONSCOpE�ORhiATHEQR HEISEXEMPTTiEREFROMANDTHEBASISFOflTHEALLEGEDEXEMP- (� V, 'iION.ANYVIOLATIONOFSECTION o3�.5BYANYAPPLIGANTFOFAPEFMITSUBJECTSTHEAPPLIGANTTO Z Re-Roof � '.ACIVILPENALTYOF,NOTMORET NFIVEHUN�FiED�OLLARS(SSOD),): ' yc� , ��,� ', ❑1,0.SOWNEROFTHEPROP�RTY,OPMYEMPLOYEESVJITH�NA�ESASTHEIRSOLECOMPENSATION. � CommefCi21 �g - �,;�. WILL DO h1E WORK,AND TWE ST UCTURE IS NOY INTEN�Ef7 oq OfFERED FOR SALE(SEC.7044,BUSI- _! �;; NESS AN�PROFESSIONS C-0�E:. E CONTRACTORS LICENSE LAW DOES N07 APPLY i0 AN OWNER OF � PROPEHTVWHOBUILOSORIMPFl V€&THEREON,�AN�WHODOESSUCHWORKHIMSELFORHERSELFOR '��� �THRDl1GHHISORHEROWN'EMPL YEE5,PROYIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EOOq m Q� OFFEREOFOHSALE.IF,HOWEVER, HE.BUILDINGORIMPflOYEMENTI550LDWITHINONEVEAAOFCOMPLE- Z,, TION,iHE OWNER-fiUILOEFi WILL AVE THE BUROEN OF PROVING iHAY HE OR SHE 010 NOT BUIL�OR w,' IMPROVEFORTHEPURP0.5EOF LE6� � ❑I,ASOWNEROFTHEPROP R7Y,�AMEXCLUSIVELYCONTRAC7INGWITHLICENSEDCONTRACTORS a,' TO CANSTRUCT THE PROJECT($�,G 7o44,BUSINESS AND PROFESSIONS CO�E:THE CONTRACTORS L4 V3Il18IlOf1 � ADJ.AREA W��' CENSELAWDOESNOTAPPLViO NONMEROFAPROPERTYWH06UILDSORIMOROVESTHEREON,AND - '��;� WHOCONTRACTSFORSUCHPRO ECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAO QUfKNTITY DESCRIPTION FEE - �.' Toq3 LICENSE LAW.). �I T � ❑I AM EXEMPT UNDER SEC.'I B.&P.Q fORTHIS REA50N � � V v ' � ,� � � � L.. � I OATE I OWNER U Z W I o�� IICEN�E�CONTRACTORS DECLARATiON W - II �� I HEREBYAFFIRM UN�ER PENALT OF PERJURY THAT I AM LICENSEO UNDER PFOVISIONS OF CHAPTER �i p:� 9�COMMENCINGWITHSECTION7oo)DFDIVISION30FTHEBUSINESSANDPROPESSIONSCODE,AND z X MY LICENSE IS�N FULL FORCEAN EF'rECT. ^ ��.•. LICENS CLASS� LJC.NO.y�� +d +�f•�'w_ � U DATE CONTRACTOF7 �" ���IlI� m. W J ���,. WORK�RS'COMPENSATION DECLARATIaN Q � �'�� 1 HEREBYAFFIRAA UNOER PENpL OFPEflJURYONE OFTHE FOLLOWING DEC�.ARATIONS: Z � � �� IHAVEANDWILLMAINTAI�ACERTIFlCATEOFCONSENTiOSELF-INSUREFORWOFKERS' � C �-''� COMPENSATION,ASPRO IDEDBYSECTION37ooOFTHELA80RCODE,FOFTHEPERFORN�ANCE U � ¢�� OF7HE WOflK FOR WFIC THIS�PERMIT IS ISSUED. W (�'j, � W ' �HAVE�AND WILLMAINTAII�WORKERS'COMPENSATION INSURANCE,AS REQl11RED BYSECTION a � Q 3700 OF THE LABOR CO�P�,FOR�THE PERFORMANCE OFTHE WORK FOR WHICH THIS PEPMIT IS /�. ISSUED.MYWORKERS'CmMPENSATIONiNSURAYCECAPRIEFANOPOLICVNUMBERAP,E: CONSTRUCTION ' �4' h Q'. � . �.. CARRIER PLAN REVIEW ��+�� Z' POUCYNUM a�� ELECTRIC o W 4 �' (�}iISSECTKKJNEmNOTB OJMFLEfE�OF7HEPERMfTISWRONEHUNDRED00LLAR5�570�ORLESS). PLUM8ING z I CERTIFYTXAT INTH6 PE FORMANCE OFTHE WORK FOR WiiICN THIS PERMIT i515SUE�,l MECHANICAL - SHALLNOTEMPLOYANY ERSONINANY��tdANNERSOASTOeECOMESUBJECTTOiHE � WORKERS'COMPENSATI NLAWSOFCAGFOFiNIA,ANDAGREETHATIFI5H0ULOBECOME INSPECTIONFEE _ �'° � Sl19JECTTOTHEW�ORKE'S'COMPENSATIONP0.0VISIONSOFSECTION37oaDFiHELABOR . = CODE,I SHALL FOA'fMN1T COMPLV WITHTHOSE PR,OVISfIONS. ISSUANCE '� ! p' DATE:��(�R� A PLiCANT: �I6+�F.�a�� SMIP �L� 0 � r I Q � WARNING.FAILUREiOSECUPEWOFKEFS'COMPENSATIONCOVERAGEISUNL4WFUL,ANDSHALLBE ENERGYP/C W,� SUBJECTANEMPLOVERTOCRIMI qLPENAL71E5'AN�CIVILFWESUPi00NEHUNDREDTHOUSAN� ENERGYPERMIT OOLLARS($1CO,DCD),INAD�ITION OTHECOSTOFCOMPENSATION,DAMAGESASPROVIDE�FDRIN ���. SECTION 3�oB OFTHE LqBOR CO E,INTEREST,ANDATTO(iNEY'S FEES. RETENTION FEE: " nW.. CO STRUCTIONLEND�NGAGENCY PRE-ALTFEE: • �1-' � � ���-���-'-`�._�-. O �� IHEREBYAFFIflMUNDERPENALT OFPERLRYTHATTHEREISACONSI'RUCTIONLEN�INGAGENCY FOF THE PERFORMANCE�F THE ORK FOF WHIGH THIS PERMIT IS ISSUED(SEG.309],GIV.G.). `_ � W Z' LENDER'S NAME � 1—' LENDER'SADDRESS � � TOTA�F�E�� �� ICERTIFYTHATIHAVEREAD7HISAPPLICA770NANOSTATETHATTHEABOVEWFORMATIONISCORRECT. � I AGREE TO CDMPLY WITH ALL CIl�1'ANO COUNTY OROINANCES ANO STATE L4W5 RELAiING TO OUILOING ��. CONSTRUCTION,ANDHEREBYAUYHORIZEREPRESENTATIVESOFTHISCOUNTVTOE�drEFiUPONhIE ���� �'�'',i ABOVE-MENTIONEOPROPERTYFbRINSPECTIONPURPOSES. COMMENTS �.l j -o, , �� ,�,�, -------- . Q',' PE�Mi7TEE E(P �' � (/�, SI PE E DATE _� '� RECPT.NO. PAID BY VALIDATION ~ ' WHITE—Depariment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOL�ENROD—File Copy,GREEN—Applicants Copy ,,. .. ;, . _. . , .. , ... ,. �. : . , �.,,: ; _ .. . `..�F� ` . � 3 z�� ..`., . .o� ��T' . 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