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HomeMy WebLinkAbout16775 --—� —-- — ,�.�--r--o".a" CITY OF DIAMOND BAR ��'p ----�--- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �' � 21825 E.Copley Drive / � (909)860-3195 Fax(909)861-3117 9, RE$S '''-���"�' BUILDINGPERMITAPPLICATION �� IRMLY o� JOBSITE APPLICATION B� � �—� � NUMB R � � #/�� ADDRESS�����f �b���rV��� �-� ` DATE e � oro ISSUE TYPE OCC APN LOT—�-��-- T�RACT DATE CONST. GROUP p OWNER ��I�yF, J rr'1 HI��s, �` ADDR�ES"S��I' �f�t��'���� �h° ZONING SETBACKS Z CITY�/LtLy�.�.� '.�5�_' ZtP��TEL�'��i"o���'� � FRONT RW ❑ APPLICANT TEL.'°7�i� �'�JCs�� �Zd' REAR ❑ Z r+� �— SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR f E� :arz;, SIDE ❑ o ADDRESS � I 6 �"��� � � PROPOSED USE CITY.��6.�lt�i'] � ZIP� TEL.�,���/.�/' o ARCH/ENG! ' W r DESIGNER NO.DWEL. NO. NO. a ADDRES5 UNITS STORIES BEDROOMS � ' CITY � ZIP TEL. � N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARAl10N SFR/ADD/REM O � I HERE6Y AFFIRM UN�ER'PENALTY OF PEfiJURY THAT 1 AM EXEMPT FROM THE CIXJTRACTORS LI- G2f2JPJC8fP01i W � CENSELAWFORTHEFOLLONYINGREASON(SEC.7031.5B�SINESSANDPPOFESSIONSCODE:ANYCITYOR (n U COUNTYWHICHREQUIRESAPERM�TOCANSTRUCT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANYSTRUC- W Pytio/DBCk Z Tl1RE.PRIOR TO ITS��ISSl1ANCE,A SD REQl11RE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � STATEMENi THAT HE OR SNE IS L�CENSEU PURSUPNT TO THE PROVISIONS OF THE CONTRACTORS LI- � � CENSE LAW(CHAPTER 9(COlAMENCING WITH SECTION 7000�OF DIVISION 3 OF THE BUSINESS AND PRO- POOI/Sp2 fESSIONSCODE�ORTHATH6'�OR�HEISEXEMPTTHEflEiROMANDTHE6ASI5FORiHEALLEGEDEXEMP- (� d. TION.ANYVIOLATIONOFSECTION o31.5BYANYHPPLICANTFORAPERMITSU&IECiSTHEAPPLICANTTO Z Re-Roof . ACIVILPENALTY�NOTMORE7HANFlVEHUN�RE�OOLLARS�$500�.): ❑I,ASOWNEROFTHEPROPFRN,ORMYEMPLOYEESWITHfNAGE5A5TrIEIRSOLECOMPENSATION, � �' Commercial � - � WILL 00 THE WORK,,AN�iHE S7R�CTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7D44,BUSI- J �, �NESS AND PROFESSIONS�CODE:TIiE CONiRACTORS LICENSE LAW DOES NOTAPPLV TO AN dNNER OF � PROPERTY WHO BUIL�S OR IMPROVES THE(iEON,AND NhiO DOES SUCH WORK HIMSELF OR HERSELF OR �����., THROUGHHISORHEFiOWNEMPL¢YEES,PROVIDEOTHATSUCHIMPROVEMENiSARENOTINiENDE�OR m ' QOFFEREDFORSALE.�F,HOWEHER,7H EBUILDINGOHIMPflOVEMENTI550LDWITHINONEYEAROPCOMPLE- 2 TION,THE OWNER-BUILDER WILL NAVE 7HE BUflDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR �, IMPROVE FORTHE PUfiPOSE'OFS�LE). w. ❑I,ASOWNEROFTHEFROPERTY.AMEXClU51VELYCONTRACTINGWITHLiCENSEDCONTFiACTOFS ' �'''., 'TO CONSTRl1CT THE PROJEGT(SEG.7064,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V2Il12t1011 A�J.AREA - W�,�'�, CENSELAWDOESNOTAPPlYTO NOWNEROFRPROPERTYWH08UIL�SORIMPfiOVESTHEREON,AND ���.''� �WHOCONTRACTSFORSUCHPFOJ�FTSWITHACONTRACTOR(S)LICENSEDPURSUANrTO7HECONTRAG QUANTITY DESCRIPTION FEE � Y TORS LICENSE LAW.). ��� ❑IAMEXEMPTUNDEIiSEC.. 6.&P.GFOFiTHISREASON Q � U I1LL � DATE OWNER U Z w � LICENSED CONTFACTORS DECLARATION w �� I HEREBY APFIRM UNDER PENALN OF PERJURY THAi I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9�COMMENCING WITH SECTION 7000)OF�IVISION 30F THE BUSINESSAN�PROFESSIONS COOE,AND Z X MY LICENSE IS IN Ft1LL FORCE A4D EFFECT. � LICENSE CLASS�"' �� LIC.N0. ������ � � V �ATE .7� �'� '� C9�� CONTRACTOR� a W � � WORK�RS'COMPENSATION DECLARATIO�'�,�✓�� �� ' a - � �. `�. ; � �.� � U � IHEREBYpFFIRMUNDEHPENALT�'OFPERJURYONEOFTHEFOLLOWINODECLARATIONS: Z Q Z� _IHAVEANDWILLMAINTAItJACERTIFICATEOFCONSEMTOSEIF-INSUREFORWORKERS' 2 COMPENSATION,ASPRO�I,IOEDBVSECTION370oOFTHELABORCO�E,FORTHEPEftFORMANCE U ¢ OF THE WORK FOR WHICF{THIS PEflM1T IS ISSUED. � �: � I HAVE AND WILL MAINTAI�WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION Q 37ooOFTHEIABORCOD5,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ' ISSUEO.MYWORKERS'.OMPE�'SATIONINS ANCECARRIERAN�POLICVNUMBERARE: CONSTRUCTION J j cAaaieR � �. �� �� � PLAN REVIEW Q �POLICYNUMBER '� �.� 0 ��li � � bZ� � ���'.T—'�'�r— �� �� ELECTRIC eL � (�}11SSECIKKJNEmNOT8�i07MRE�EDOF'iHEPERMRISWRONEHUNDRED00LlAR5�E10�ORLESS). PLUMBING w �j 2�"� Z ICERTIFYTHATINTFj�PERFORMANCEOFTHEWOPoCFORWHICFiTHISPERMITi515SUED,I MECHANICAL C!} SHALL NOT EMPLOYANY�ERSON IN ANY MANNER SOAS i0 eECOME SUBJECT TO THE � WORKERS'COMPENSATIONLAWSOPCALIFORNIA,ANDAGREETHATIPISHOUL�BECOME INSPECTIONFEE - � Sl18JECT i0 THE WOFKERS'COM?ENSATION PROVISIONS�F SECTION 3700 OF THE LABOR , "}�� �� � W�E,�SHALLPORTHWITIICOMPLYWITHTHOSEPROVISIONS. ISSUANCE �^"'""'^ �.�.. "� rac o � O " , ��i ..� � . ,...�r �� DATE: APPL16ANT. SMIP 2 J WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS 11NLAWGIJL,AND SHALL BE ENERGY P/C � r - � SUBJEGTAN EMPLOYER TO CPIM7�JAL PENALTIES AND CIVILFINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT i � 9' ���A� µ '} DDIIARS(51aD.Oco),INADDITIONYOTHECOSTOFCOMPENoATION,DAMAGESASPftWIDE�FOftIN � ,' J� SECTION 3�OB OFTHE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: 'i � w z,__,-T, n.. CO�ISTRUCTION LENDING AGENCY pqE-ALT FEE: � "``�'• O _._ �__._._..w _...,..,. F �..._W___ � � IHEREBYAFFIRMUN�ERPENALTh'DFPERJURYTHATTHEREISACONSTRUCTIONLENDINOAQENCY FOF THE PERFORMANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEG.3091,dV.C.�. . Z W j LEN�ER'S NAME 9 1— LENDER'SA�DRE55 � TOTALFEES �+ � ICERTIFYTHATIHAYEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. ��'�:\ � � 1 AGREE TO COMPLY WIiH PLL CITY AN�COUNTY OR�INANCES AND STAiE L4W5 FELATING TO BUILDING �"� � CONSTFUCTION,AND HEflEBY AIJI'HOR2E REPflESENTATIVES OFTHIS COUNTYTO ENTER UPON THE Z A60VE�MENTIONE�PROPERTY FbR INSPECTION PURPOSES. COMMENTS � ' �/��C:' �.d /�-'�'-�'` m PERMITTEE NAME(PRINT� $'��' C.I� ��`' �1 � SIGNATUREOFP .�� �� • DATE � = RECPT.NO. PAID BY VALIDATION ~ � WHITE—Department Copy,YELLOW—Finance Copg PINK—Assessor Copy,GOLDENROD—Flle Copy,GREEN—ApplicanYs Copy , � .. . _ .,,. , �� "" _ '�6 d;rre.�a�,§�� .�:� � � h� � , � ;7 � a :� d"�. ,� " r + � a a�s�:� a �,' a *°� � � �a _. : a M �-�;^�� � s^g ��,1�'�', a' . '. a § � " l . 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