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HomeMy WebLinkAbout12225 (14) i � CITY OF DIAMOND BAR .—^-^� ---- " — DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� � 21660 E.Copley Drive Suite 190 �f' PRESS � (909)860-3195 Faz(909)861-3117 � '��'A�° BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE APPLICATI PERMIT�7"Z� P/C �. ADDRESS` o DATE NUMBE �� # c� ISSUE TYPE OCC .- APN LOT TRACT DATE CONST._ GROUP p OWNER���''�-��—�'���� ADDRESS • �� ZONING SE.TBACKS g CITY ZIP '-�TEL.`�� FRONT RW ❑ APPLIC ' TEL. REAR LI SIDEJSIQE STREET RW fl � CONTRACTO rr - SIDE LI___ _ Q CDDRESS Z� - TEL.� PROPOSED USE d��'� ��'V' o� ARCH/E - � W DESIGNER — NO.DWEL. NO. NO. a ADDRESS UNITS STORIES _ BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFRlADDlNEM O 0 I HEREBYAFFIRM UNDER PENALTV OF OE0.tt1RY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � GdfdJB/CefPOli W CENSELAWFOqTHEFOLLOWIN6REASON(SEC.7031.SBU6INESSMIDPROFESSIONSCO�E:ANYCITvoR U �p{lp(TYNRIICMREQUIRESAPERMIiTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,OflREPAIRANYSTRUP W P8f10/DBCk Z� NRE,PRIOR TO ITS ISSUANCE.ILLSO RE�UIRES THE MPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMEM THAT HE OR SHE IS LICENSED PUR3UANT TO THE PROVISIONS OF 7HE CONTRAC70R5 LI- W � CENSE UW(pUPTER e(GOMMENCIN�WITM SECTION 7ooa)OF DIVISION 30F THE Bl1SINESS AND PR0- �'1" PODVSPB y FESSIONS CODE)OR 7HAT HE OR SHE IS E%EMPT 7HEREFROM ANU iHE BASIS FOR 7HE ALLEGED E%EMP• � V TION.ANYVqLATiONOFSECTION7037.69VANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Root � ACML PENALTY Of NOT MORE THAN FNF.Hl1NORED DOLUIRS(SSOD).): � f71,ASOWNEROFTHEPROPERTV.ORMYEMPLOYEESWITHWAGE5A5TMEIRSOLF.COMPENSATION, � COmmefCial S WILL DO THE WORK,ANU THE STRUCTURE IS IdOT INTENOED OR OFFERED FOR SALE(SEC.704a.9USI- J N NESSAND PFbFESSION3 CODE:THE CONTRACTORS LICENSE LAN!O�JES NOT A?PLY TO AN OW4ER OF j PROPER7V WFiO BUIIDS OR IMPROVES 7HEREON,AND WHOOOES SUCH WORK HIMSELF OR HEflSEIFOR � THROU(iHMi50RHEROWNE1dPLOYEES,PPOVIDEDTHAT5UCH11AGROVEMENTSARENOTINTENDE00R C� p OOFFEflEDF9ASALEIF,ViOWEVER�M1IEBURDINGOflIMPROVEMEN71S50LDWI7HINONEVEAqOFCOMPLE �. z TION,TNE OWNER$UIlOEF WILL MAVE THE BUfl�EN OF PROVING THAT HE OR SHE DID NOT BUIID OR � IMPROVE FOR 7HE PUp7�5E oF SALE7. M W ❑I,ASONRJEROFTHEPROPEKfY,M7EXCLUSNELYCONTRACTINGWITHLICEN5EDCONT1iACTOqS � � Q TO CONSTflUCT THE PR0.1EC7(SEC.7044,BU5INESS AND PFOFESSIONS CODE:TME CONTRACTOqS U� V81U8110f1 ADJ.AREA W CEN5ELAWDOE5NOTAPPLY70ANOWNEHOFAPROPERTYWHOBUILDSORIMPRDYES7HEREON,AND � = VhWCONTMCTSfaRSUCHPR0.IECTSWI7HACONTRAC70R(5)L10EN5EDFURSUANT70THECONTRAC- QUANTITY DESCRIPTION FEE ' ~ TORSLICENSEUW.). � J � Li I A�1i EXEMMUNDER SEC. �.&p.C.FOR THIS REASON U � � � � DATE OWNER__ _""__'_-- U W � LICENSED CONTRACTORS DECLARATION W � IMEREBYAFFIflMUNOEflPENALTYOFPERIUHYTMATIAMLICENSEDUNDEflPROVI510V50FCMAPTER � p. B(COMYENCINO WITH SECTION 7aaoj OF�IVISION 30F THE BUSINESS AND PROFE5510NS COD[.AN� Z `X MVl10ENSE'SINNLIFORCEPNDEFFECT. //'' m �� � LICENSE CLASS LIC.NO.��� � � .� �_._'_'_":_ WDATE__ ' CONTRACTOR,_� a p � WO ERS'COMPENSATION DECLARATION � § � E � IHEREBYAFFIflMUNDEflDENALNOFPERIUflYONEOFTHEFOLLOWINGDECLPRATIONS: Z E � IHAVEANDWILLMAINTAINACENTIFlCATEOFCONS[NTTOSELF-INSUREFORWORKER5' 2 � � �COMPENSATION,AS PflOVIDEO BY SFCTION 37n00F 7HE LABOR CODE,FOR THE PERFORMANCE W OF THE WORK FOR WHICH THIS PF.RMIT IS ISSUED. � � W _I NAVEAND WILL MAIMAIN WORKERS'COMPENSATIO�INSURANCE,AS REQUIRED BY SEC710N Q37000F TME LFE30R CODE,FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS `� � �G� � _ ISSl1ED.MY WORKEHS'COMPENSA710N INSURFNCE CNRRIER AND POLICY NUMBER ARE: CONSTRUCTION __ ___ - __ _,__ � � CARHIER_ r� � PLAN RFVIEW ... . ..- -----.--......--.--... --- � � � �-------- � ZPouCYNUMB —�.._' —..— ELECTRIC ___...___..__.___. _.—_—__..—.___..______.___._.—__ .— Q 0 (fHI55ECTpNNFIDNOTBE � OFThE fSFORONEHIN.fIFiEDDOLIPAS(btoo)OIiLESE) PLUMBING ..'... .._.._____ --_._'.'_'_"_ '_"_._'___--- Z ICEfl71FYTHATINTHEPERFORMANCEOFTHEWOflKFORWHICH7FIISPEflMITISISSUED,I MECHANICAL .__ ___.__ ______ _.__,____— � (� SHALLNDT EMPLOYANY VERSON IN ANY MANNER 50 AS TO BECOM[SUBJECT TO THF: �('� � WORKEFS'COMPENSATIONLLWSOFCALIfORN1A,ANDAGREETHATIFISHOULD6ECOME INSPECTIONFEE _ _ ` � --------------- -- SUBIECT TO THE IMOHKEFlS'COMPENSATION PROVISIONS OF SECTION 37aa OF THE LABOR � � � ISSUANCE "" ' ' � COO.I SHALI�ORTHWITH COMPLY WITH THOSE PROVISI N& � � DATE: � � _ APPLICANT: " ��/�. SMIP 1 � � ENERGY P!C J WARNING: AILURE TO SECUPE WOflKEHS'GOMPENSATION COVEflAOE IS UNLAWFUL,PYO SNALI BE ' "------""""'—' """--'---' " '-"—"'—"-- �y SUBJECTA EMPLOYERTOCRIMINALVENALTIESANDCIVILFINFSUPTOONEHUN�REOTHOl1SAN� ENERGYPERMIT DOLLARS(S�W.000),IN ADDI7IGY TO THE COST OF CAMPENSA710N,00.MRGE5 RS PRDVIDE�FOR IN --'—'--- --"----------'------'--'-- ¢ SECTION37080FTHELABORCODE,INIF.HEST,ANDATTORNEYSFF.ES, RETENTIONFEE: _..____„_,___._____,_ ___,_ _ d CONSTRUCTION LENDING AGENCY pRE-ALT FEE: � "` ' — � I1IEREBYAFFIRMUN�EHPENALTYOFPERJURY7HATTHEFEISACONSTRUCTIONLENDINGAGENCV _ _ My FOR THE PERFORMANCE OFTHE WORK FOR Whi1CH THIS PERMIT IS ISSUED(SEC.3a9],CIV.C.�. �;+1 � '�,y w ""_—' ✓ _ � LENDER'SNAME_"'_'_' '_-- .. ___—_'___'__ F— LENDER'SAUDHF.SS ____ W ICERTIFVTH/1TIH/VEREADTHISAPPLICATIONAN�STATETHATTHEA90VEINFOPMATIONISCARRECT. TOTAL FEES ` � � IAGREETOGOMPLYWITHPLLCITYANOCOUNTVORDINANCESANOSTATELAWSRELATINCTOAUIL�ING CONSTRUC710N.ANO HEREBY AUTHORIZE REPRESENTATIVES OF TH�S COUNTY TO ENTER UPON TME _— � ZABOVE�MEMKKJEO PROPERN FOF INSPECTION PUfiPOSES. p°� ! GOMMENTS _.0__�5+1=� f:" !At � � �� \.: � _ —_ m PERMI E (PRl _'_ __— ' ' ¢ _ _ Cn __ ' � SIONATUREO E � = RECP7 N0. ` _PAID BY VALIDAl10N _� ~ WHITE—Department Copy,YELLOW—Fv�ence Copy,PINK—Assessor Capy,GOLDENROD—Fila Cvpy,GREEN—Applicant's Copy _ ._ .. ... ..._.._ _ _ _ ... . }F � - .. ( _ . ., _ ,_ . _'. . . _ .....__..... _,.. .. ._..._. _ ; , _. .. . - -I ' . �., � ; i i �� � i ' � . � - � - . . � • � - �.i, ` � � � ' � � - � � ;� - ( � ' � � , ' I � , ' � � ' � ' � ! , � ' � ' � . �� i � 1 i � I � i i . �� i i - .I . + i � i . ; : I , I . . . . . � � � . � . � � r , � �ss : � ' I . , : " �;:s�, � t ,. i , � ' ' ; r � . — - —�-- �— -- ' 5� . ' ___i f ' 1 . f � ' ' � 1 . , i i } . �j 3' .i . .� � i 4 i I I _ , . � . � - . � ! i � �� � ! 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