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HomeMy WebLinkAbout17466 (23) _ . __ --. . -- _ � �y � ��� CITY OF DIAMOND BAR ,; � . - --�--- I3EPAR'I'MENT OF CONIMUNTTY&DEVELOPMENT SERVICES ��' ilys��°�'i;�� 22825 E.Copley Drive (909)860-3 i95 Fax(909)861-3117 PRESS ''"-Y�y��' BUILDINGFER16I1'1'APPLICATION FIRMLY � JOBSITE ^� r� �3�,� �/ APPLICATiON ^7 PERMIT P!C o ADDRESS� f J T� �"d/ /��`�'���� � DATE 4�L�("`�V NUMBER_���L��# � - ISSUE TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �`T�#C..�+�i� ��-�5� o ADDRESS_'�Z--i'1�'S'� t"���.s�� '�-� ZONING SETBACKS Z CITY�IA''�as�"� 8��--ZIP I'"Z TEL���J�'�I�Zi`3� FRONT RW ❑ o APPLICANT TEL. S DE/SIDE STREET RW ❑ z ¢ CONTRACTO �� �''�s-�� ��f ` '�'�C- SIDE ❑ ADDRESS � 4. 'J�4i- 5^+` � � CITY`I�����r'�`� ZIP`�"� � TEL. ��7°�� e� PROPOSED USE �/�i��.'�' ��df+'l��G?'�'�'" o ARCH%ENG/ �z DESIGNER NO.DWEL. NO. NO. � A�DRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS m cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM � O . p I HEREBY AFFIRM UN�EF PENALTY OF PEflJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- G8�d9E/C8f(10fI W CENSELAWFORTHEFOLLOWINGFiEA50N(SEC.7o37.56U51NESSANDPFOF'cSSI0Y5CODE:pNYCITYOR (n U COUMYWHICHftEQUIRESAPERN�ITTOCONSTHUCT,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W . TUflE,PRIOR TO RS ISSUANCE,pLSO RE�UIRES THE APPLICANT F�R SUCH PERMITTO FILEA SIGNED W Petlo/DeCk 'STATEMENT THAT HE OR SHE IS LICENSED PUflSUAM TO THE PROVISIONS OF THE COIJrRACTORS LI- �,� CENSE LAW(CHAPTER 9(COMMEIJCING WITH SECTION 7ooa)OF OIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB O FESSIONSCODE)ORTHATHEOR$HEISEXEMPTTHEFEFROMANDTHEBASISFOFTHEALLEGEDEXEMP- (� V TION.ANYVIOLATIONOFSECTION'7031.5BYANYAPPLICANTFORAPERMITSU9JECTSTHEAPPLICANTTO Z R@-R001 �. .ACIVIL PENALTY OF NOT MORE iHAN FIVE HUNDRED DOLLA(i5(55DoJ.7: ' � ❑I,ASOWNEROFTHEPROP�RTV,ORMYEMPLOYEESWITHY✓AGESASTHEIRSOLECOMPENSATION, � � Commercial -- �� WIIL UO THE WORR,AND THE STRUCTURE IS NOT IN7ENDED OR O�FERED FOR SALE(SEC.70t4,BUSI- J � �NESS ANO PROFESSIONS CODE:THE CONTRACTOFS LICENSE LAW DOES NOT APPLV TO AN OWNER OP � PqOPEflTY WHO BUILOS OR IMPROVES 7HEREON,AN�WHO�OES SUCH WORK HIMSELF Ofl HERSELF OR fL THROUGH HIS OR HER OWN EMPLAVEES,PROVI[7ED THATS'JCH IMPROVEMENTS ARE�OT INTENDEO OR m �'. OFFERED FOR SN.E.IF,HOWEVER„`fHE BIIILDINGOR IMPROVEMENT IS SOID WITHIN ONEYEAROF COMPLE- Z. .TION,THE OWNER-BUfLDER WILL''�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIL�Ofl , �,� IMPROVEFORlHE'PUFPOSEOFSALEJ. ❑I,AS OWNER OFTHE PFOPERN,AM EXCLUSIVELY CONTRACTING WITH LICENSE�CONTRACTORS �� TO CONSTRUCT THE PROJECT(S�CJo44,BUSINE55 AND PROFESSIONS CADE:THE CONTRACTORS LI- VelUetlon ADJ.AREA LLI' CENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTV WHd 8111LDS OR IMPROVES THEREON,AN� � WHOCANTFACTSFORSUCHPROJECTSWITHACONiRACTOR�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY � DESCRIPTION FEE Y TOHS LfCENSE LAW.). , � � �I AM EXEMPY UNDER SEC.' B.&'P.G FOR THIS REASON J � U � � �'1' �ATE OWNER � U Z W � � LICENSED CONTRACTORS DECLARATION . � ¢ . . � I HEREBYAFFIflM UNDEF PENALTY aF PERJURYTHAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � '�. 9(COMMENCING WITH SECTION 7Q00)OF DIVI510�30F THE BUSINESS AND PFlOFESSIONS CADE,AND z X . MY LICENSE IS IN FULL FORCE ANp EFFECT. , � .UCENSE CLASS �~�� LIC.NO. ������ Ga++,.��f j :,v DATE � ��4.`^D'"'4` ' CONTRACTOR�t•..��SI F'I�+"'*�I^'�a' a � L1� ' � $ �}I�G`.u'�4�1f��� : , �� , WOflKERS'COMPENSATION DECLARATION Q �� � '9 � � � I HEREBV AFFiRM UNDER PENALTy OF PERJURY ONc OFTHE FOLLOWING DECLARATIONS: Z w 3+�--�� ' �� �yy��' a !rl 7 c+ 'z _IHAVEANDWILLMAINTAI�JACERTIFICATEOFCONSeNT70SELF-INSUREFORWORKERS' _ ¢ CAMPENSATION,ASPROVIOED'BYSECilON37ooOFTHELABOPCODE,FORTHEPERFORMANCE W Q OF THE WORN FOF WHICN THIS PERMIT IS ISSUED. � � _I HAVE AND WILL MAINTAIN WORKEflS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION , Q 3700OFiHELABORCO��.FORTHEPERFORMANCEOFTHEWOFiKFORWHICHTHISPERMl715 � � ISSUED.MY WORKEAS'CbMPENSATION INSURANCE CARRIERANO POLICY NUMBER ARE: CONSTRUCTION jcnRaiEa - � PLAN REVIEW . � POLICYNUMBER ' Z , ELECTRIC Q . � (IHISSECTIONNEmNOTBEOJMPLEfE00F'}EPERMRISFORONEHUNDREDDOLLA{iS(5100)ORLESS). PLUMBING z ICERiIFYTHATINTHEP�flFORMANCEOFTHEWOP.KFORVJHICHTHISPEFMITI51S5L;ED,I MECHANICAL - '� SHAIL NOT EMPLOY ANY pER50N IN ANY MANNER SOAS TO BECOME SU&IECT TO THE (n WOqKERS'COMPENSATIdNLAW50FCALIFORNIA,ANDAGREETHATiFISHOULDBECOME INSPECTIONFEE SUBJECTTOTHEWORKERS'COMPENSATIONPFOVISIONSOFSECTpN OOOFTHELABOR � K� � CODE�,ISHALLFORTHWIh1COMPLYW�THOSEPR ISIONS� ! ISSUANCE ��` 0 °�/ti� p �ATE: �1-'��`� � ApPLICANT. / �� SMIP �, WARNINGFAILURETOSECUREWORKERS'COMPcNSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C LL SUBJECTA,NEMPLOYERTOCRIM�NALPENALTIESANOCIVILFINESl1PTOONEHIINDRE�THOUSAND ENERGYPERMIT � DOLLARS(E1 W,oW),IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�E�FOft IN �� J�� SECTION3�oe OFTHE LABOR CO�E,INTEr7EST,ANO ATTORN[Y'S FEES. RETENTION FEE: �`�p OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBV/iFFIRMl1NDERPENALTYOFPErIJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV f-OR THE PLRFORMANCE OF THE WDRK FDR WI�IICH 7ryi5 PERMIT IS ISSVED(SEC.309'!,CIV.C.). . Z LC1 �, LENDER'S NAME k'-� LENDEH'SADDRESS � TOTAL FEES �Q �-� -" � ICERTIFYTNATIHAVEREA�THI5APPLiCATIONANDSTATETHATTHEABOVEINFORMATIONISCORflECT. ' �� I AGREE TO COMPLY W1TH ALL CITYAND COUNTY ORDINANCES AND STAiE L4W5 RELATING TO Bl11LDING �, CONSTRUCTION,ANOHEHEBYAUTHORIZEREPRES�NTATIVESOFTHISCOUNTVTOENTERUPONiHE Z. A80VE�MENTIONEO PROPERTY FOR INSPECTION PUflPO5E5. COMMENTS �' ��+�-I� v����V � 5. m�� BE E NAM. RINTI s tn �d ���9.a-v..e ��_.�7 -� i ��. SIGNATVREOFPEPMITTEE DATE = RECPT.�O. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Co PINK—Assessor Co GOLDENROD—Flle Co GREEN—A IicanYs Co PY. PY, PY� PP PY ' .�.�f . ...... ..... �. : ..... ... . ..._ ... ,.., ,.-..�. ;......- ._ ...:,i., � -. �% . - - . . _ � +, n ...� . "�.#"r . 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