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HomeMy WebLinkAbout14227 (20) ,r CITY OF DIAMOND BAR --r' � -- �� --- DEPARTMENT OF COMMUNITY&.DEVELOPMENT SERVICES k � . 21660E.CopleyDriveSuite290 (909)860-3195 Fax(909)861-3117 PRESS �'°�" BiJILDING PERMIT APPLICATION FIRMLY � JOBSITE (� APPLICATION � PERMIT r// o ADDRESS ��y�� ���C ��l Y�f+y'� iJr DATE��9�NUMBER � /��� q/C � ISSUE TYPE OCC APN LOT TRACT —,.,� — —, DATE CONST. GROUP p OWNER _. `��afA-1-�—�-yys " L ✓ p ADD S �I �I l�3' b Y1�/1 � ►P ZONING SETBACKS � FRONT RW tl._ _ CITY 0 h ZIP TEL. 4 REAR U_ APPLICANT TEL. SIDElSIOESTREET_ RW Cl � GONTRACT �„ (OJ1� ,�b r�<, SIDE �]__ ApDRESS � CITY`�py[�k-hf I 0 ZIP pTEL. a.{ PROPOSED USE i� o ARCHIENG/ DESIGNER aiZi NO.DWEL. !NO. NO. n. ADDpESS cn -- -------- UNITS STORIES _ BEDROOMS � CITY __ ZIP TEL. � tn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER•BUILDER DECLARATION SFR/ADD/REM O � [] I HEREBY�FFlRM UNDER PENALTY OF PERJURY THAT 1 M1 EXEMPT FHOM THE CONTRACTORS LI- GafdJB/Ce(pOff ! W CENSEUWFOHTHEFOLLOWINGREASON(SEC.7031.SBUSINESSAN�PROFESSIONSCODE:ANYGNOR (� � COUNTY VhI1CH REIXIIRESAPEPMITTO CANSTRIICT,ALTER,IMPROVE.OEMOLISH.OR qEPAIFl ANY S7AUP i W TURE,PfllOfl TO 1T3 l59UANCE.AL50 REOUIqES THE APPLICANT FOfl SUCH PEHMIT TO FILE A SIGNED w PetiO/DeCk � � STATEMEM TNAT HE OR SNE IS�ICEN5ED PUHSUPNT 70 7HE PROVISIONS oF THE CONTRACTORS ll- � ` � CENSEUW(CHAPTERB(LOMMENCINGWITHSELTION�oao)OFDIVISION3OFTHEBUSINESSANDPqO- POOVSpd � FESSIONS COUE)OR THAT HE OR SHE IS E%EMPT THEflEFROM ANO THE BASI5 FOFi THEALIEGED EXEMP- TKKi.ANYYpLATIONOFSECTIO1V70.71.5BYANYAPPLICANTFOHAPERMITSl1BJECTSTHEAPPLICANTTO z Re-Root � � ACIVILPENALTYOFNO7MORETNANFIVEHUNDREDUOLLAflS�5500).): � � ❑I.ASONTIENOFTHEPROPERTV,ORMVEMPLOYEESWITLIWAG[SAS7HEl{iSOLECAMPENSATION, L� COfllfflBfC18I � 141LL 00 THE WOfl.K,ANO 7HE STPUCiURF IS NOT INTEN�ED Or�OfPERED FOR SALE(SEG.�oia,BUSI- J � NESS PN�PiiOFESS�ONS CODE:THE CONTRAC.TORS LICENSE LAW DOES NOT APPLY TO AN OWNEH OF = I i iROPEq'f`/W}f0 BUILDS OR IMPROVES THLFEON,AN01YH0 DOES SUGH WORK HIMSELf OR HERSELF OR � 7HROUGHHI80RHEROYMEMPLOVEES,PRO`ll�E�hIATSUCHIMPROVEMENiSARENOTINTENOEDOR CO � � OFFEREUWHSPLEIfiMOWEVERIME9UIlAINOORIAIPHOVEMENTISSOIDWRHINONEYEAflOFCOMPLE- I TION,7HE OWNER-BUILOEfl WILI.HAVE THE BUR�EN OF PROVING THR1'ME OR SHF.DID NOi BUILD OR ' � IAIPqOVE FOR THE PUFPOSE OF SAIf.J. ; W ❑I,ASOWNEROFTHEPROPERTY,AAIE7(CLUSIVELYCONTflACTMGWITHLICENSEDCONTRFCTORS � �[ 1'O CONSTRUCT THE PR0.IECT(SEC.70�0,fiU31NE�5 AND PROFESSI045 COD�:ThE CONTRACTORS U- VelllffiIDIi�t ADJ.AREA W. CEN5EUW00ESND7APPLYTOANOY✓NEROFAPROPERTYYIHOBUILDSORIkPHOYcSTl1EHCON,AN� ---"--'----- ------ f WFiOCONTRACTSFOflSUCHPROJECTSWITHACOMTqqCTOR(S�IICENSEDPURSUANiTOTHECANTAqG QUANTITY DESCRIPTION FEE ! 70R5 LICENSE LAW.�. oI�!Al.!EXEMPT UNDERSEC ____.__ _____ _,__B.&P.C.FON THIS FEA50N Q ^V � 3 � � ---- — s I DATE.__`_ OWNER_-."'_' '.'__"____ V � � LICENSED CONTRACTORS�ECLARATIOTJ W � 1 HEREBY AFFIHM UNDER PENALTY OF PERIURV iHAT I AM LICF.NSED UNDER PfiOVI510N5 oF CHAP7ER � � � 9(COMMENCINOWITNSECYKNJ7000)OFDIVISION30FTVIEOUSINESSAN�PkOFESS!ONSCODE,ANO Z � MY UCENSE IS IN F'ULL FORGE AND EFFECT. V (,��� �_l�— '� � � _ m �� 1r i1 �°Yl t+►r � LICENSECLASS� LIC NO..__ _____ j C VDATE i l� •2_.�`�C'S CONTRA ��t � W __ s�a-�._ _ ' v ttt�a..�._ � WORKER3'COMPENSATIO ECLARAT�ON a � I HEFEBY AfFIRM UNDEFl PENPITV OF PERIURV ONL OF?HE FOILOWINC OECLARATqNS: Z � 0 _ IHAYEMlDri1Ll�7AINTPMIACERTIFICqTE9FWN5ENTTOSELF-INSUREFORWORKEAS' ¢ � � = i CqMPENSATION,A9PROVIDEDBV5ECT10N3�ooOFTHEU80RCWE,FORTHEPEFFORMANCE W � F THE WORK FOR WHICN THIS PERAAIT IS ISSUEO. a � ! � IHAVEMIDW!ILMNIMAINWORNEHS'COMPFNSATIONIN9UMNCE,ASHEOUIREOBYSECTION I � 3)DO OF THE L160R CODE,FOR TH[PERFORMANCE OF THE WORK fOR WHICH THIS PEflMiT IS ' � I5SUFA.MYWOR S'CO�PE�A7IDNINSl1RMCECARRIERAN�POL'CVNIIMBFPAFE� CONSTRUCTION ,,,__ :- ._„__ ,____ ,_ � cA�:�iea_. �__ . PLAN FiEVfEW _,_=���:3 '�-• i e ^ ----------- - �-;�j. -.._..------ --"'— � POLICY NUMCIER__y,.�_`_ I c���--. FIECTRiC '�.� I Q ---'--- ...-/� --'--'-"- ------ , � (f7tl33ECfi0tJM1'EtLtfO7BFa.ri4'�_EIED(:FTCI+�'iA,'flASFOF;qVEFR/n9fiEDCOtl13?S(Sto�)OfiLECS} PLUMBING g� � -.---_---- � -�,,y--- �=..��--- Z I CEIITIF1'THAT M THE PERFOW�ShNCE OF 7NF WORK FOfl WHICH TNIS PERMIT IS ISSUED,I MECHANICAL '-q��.______� :) :4� �.. I C�S SHAI.LNOTEMPLOYPNYPERSO!lINANYMANNERSOASTOBECO4ESUBJECTTOTH[ !. —�,1��— �_. ..• �;... a.° Uj WORKERS'COMPENSATION LAWS OF C RNIA,ANO AGREF.THAf If I SHUULU BECOME INSPECTION FEE ➢�_�y _�;��_ � ___ , - SU&1ECTTOTHEWOR%ERS'COMPE SNO PROVISIONSOFSEC710Y. THELA90R ��'•f,6T�h���y 9;'yirl� � ISSUANCE '=q' c:•s/',.., .�4---.— � CADE,I SHALL FONT�WITH COMPLY fOSE PROVISIONS. _. _.__.� k� - 1, /� � �'Y.1�_�a,?�— - (� DATE:_�..V•Z�"'"1 1 APPUCAN: .. .�-A.L��^°o� ._ .._'.'- SMIP __..._ y.,..r(,,��.'�''L__"_.-...._—.' - I �t ea�\ W � ,..��.�.: I J WARNINCPAILURETOSECUREWORKEPS'COMPENSATIONCOVERACEISl1NU1WFlIl,ANDSHALL ENERGYP/C _.,_.__ ,.___=_,�_, _,___ I �y SU&IECTANEMPtOVEftTOCRIMINALPENALTIESNN�CIVILFINESUPTOONENUNDFlED1HOl1SAN0 ENERGYPERMIT DOLLAflS(5700.0o0),INADDITIO4TOTH[CUSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN --- - -�---. ----- -.----..._—. � J SECTION 3�OB OF THE L4BOfi(.'O�E,MTEREST.ANDATTOPNEY'S FEES. RETENTION FEE: __ I � ...'____--__ __- � CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � � ------- ----'- ------'--- � � IHEREBYAFFIfltAUNOERPENALTYOFPERJUFVTHATTHEREISACONSTHUCTIONLENDINGHCENCY i d FORTHEPERFOflMANCEOFTHEV✓ONN�ORWitICHTHISPEHMITISISSUED�SEC.3097,CIV.C.). 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