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HomeMy WebLinkAbout10419 --�`` CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT .,,.W 21b6Q E.Coplcy Drive Suite•190 PRESS (909)8G0-3195 Fax(909)861-3117 '""' BUILDING PERMIT APPLICATION FIRMLY o�� JOBSITE "1���tS f"• f,�' ��u,�y ���� APPLICATION � ( �� NUMBER� #/C � ADDRESS �/ V � w�'� ���• �� ° DATE c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER �Y�-�7 O o ADDRE55 ��JVK.t- ZONING SETBACKS w � FRONT RW ❑_ Z, CITY ZIP TEL. � '3 — o APPLICANT Z`�1��"l.—� TEL. �� S DE/SIDE STREET RW C7 z m CONTRACTO Yl ` .C�l�'Ci1� SIDE � ¢+ ADDRES �� � � � CITY ' � ZIP E11 7 0 TEL. a� � PROPOSED USE o ARCHIENGI � W� DESIGNER NO.DWEL. NO. NO. o. ADDRESS UNITS STORIES BEDROOMS _. CITY ZIP TEL. c�i�" DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANAIUATION O- OWNER•BI:ILDER DECLARATION SFR/ADD/REM � I HEREBY AFFIRIA 11N0EP PENALTY OF PEfiJURY THAT I 11M E%EMPT FROM THE CONTRACTOHS LL G91899/COfPOfI W CENSELAWFORTHEFOLLOW�NOflEASON�SEC.7031.5BU51NESSANDPROFESSIONSCODE:ANYGTYOR (n ZCOUNTVWrIICHREOUIRESADERIAITTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORflEPNRANYS7Rl1C� W p8�10l�BCk w TUflE.PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUGM PEqMIT TO FlLE A SIGNEP w STATEMENT TH�Y HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTRACTORS LF � CENSE LAW(CHAPTER 9(COAIMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PAO• u' PaoVSpa fESSIONSCODE)OflTMATMEORSHEISEXEMPiTHEPEFROMAND7HEBfS15FOR7HEALlEGEDE7fEMP• (�} � TION.ANYVIOLATIONOFSECTION)0]t.6BYANVAPPLICANTFORAPEflM17SUBJ[CTSTHEAPPIiCPNTTO Z Re-Roof F,,,' FCIVIL PENAITY OF NOT MORE TMAN FNE HUNDREO OOlLARS(SSoo)�'. � CII,ASOWNEROfTHEPROPEflTY,ORMYEMPIOVEESWITHWA�ESASTHEIHSO4ECAMPENSATbN, Q Commerciai Z WILL DO THE WORK,AND THE STRUCTUR[IS NOT INTENDED OR OFFERED FOR SALE(SEC.7066,91151. J NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICEN3E LAW DOES NOT APPLV TO AN OWNER OF � PfWPERIYV.'N08Ud,OSOR�MPROVE6THEREON.ATIDVMODdESSUCHWOiiKH1A1SELFOqHERSELGOA � � THROUGHHISORXERONMEMPLOYEE5.PROVIDEDTHATSUCHIMPFOVEMENTSARENOTINTENOEDOR m w' OFFEflEDFORSALE.IF,HOWEVERTHEBUILDINGORIMPqOVEMENTIS50LDWITHINONEYEAROFCOMPLE- 0- TION,THE OWNER�BUILOER WILL HAVE TNE BUROEN OF PRWING THAT HE Ofl SHE OID NOT BUILO OR Z IMPROVEFORTHEPUPPO$EOFSPLE). _ l71,ASONRJEROfTHEPpOPERTY,MIEXCLUSIVELVCONTRACTIN4WITHLICENSEDCONTRACTOqS �� TO CONSTRUCT TNE PRQIECT(SEC.70<0.BUSINESS IWD PROFE5910NS CODE:7ME CONTRACTOHS LI� \/aNBIlOf1�_! ADJ.AFEA W. CENSELAWDOE9NDiRPPLY70ANOWNEROFAPROPERiVWHOBUILD50RIMPROVESTHEREDN,AND � WHOCANlRACTSFORSUCNPROJECT3WITNACAN7RACTOR(S�LICENSEDPUPS�ANTTOTNECONiPAC QUANTITY DESCRIPTION FEE Y TORS UCENSE LAW.�. J I �, ❑I AM EXEMPT UNDER SEC____„ __ B.8 P.C.FOR 7MI5 flEA30N Q � 3 _- -- s ' V' DAT[__ OWNER , � Z _ _ W � � IICENSED CONTRACTORS DECLARATION W � I HERF9YAFFIHM UNDER PENPLTY OF PERJURY TMqT I AM UCENSEO UNOER PROYISlONS QF CHpPTER � s �� i ' d 9(COMMENCINO WITH SEC710N 7000�OF DIVISION 9 OF THE BUSINESS AtJO PflOFESSIONS CODE,AND Z ✓� `X W LICENSE IS IN FULL FOiiCE AND EFFECT A �/ (� m � LICENSE CLA, �5(_7.�/4A4'��=,, .le�_ LIC.Nb.�/��� � V DATE P ,7 __ CONTRACTOR � a W -y �� WOHKERS'COMPENSATIONDECLARATION �p-CCi"� Q � "' � t� U N IHERE6VAFFIRAIUNDERPENALTYOFPERIUFiYONEOFTHEFOLLOWINGDECLARATIONS: .�g Z Y a 0 _I HAVE AND WILLMAiNTAIN A CERTIFICA7E OF CONSENTTO SELF-IN�UPE FOR WORKEqS' _ �� CAMPENSATION,AS 7ROVIDED BY SECTION 3700OFTHE LABOR COOE,FOR 7HE PEREORMANCE `U OF THE WORK FOR WMCH THIS PFRMIT IS ISSUED. � W y � V 1 N.AVE AkD WILL MAI4'RI.Y IhORKERS"..'OMPENSATION Ih£L'RANCE,AS REGIIIRED 6V SECi IdY Q 3laa OF THE LABOR COOE.FOR THE PERFORMANCE OF THE WORN FOq WHICH THIS PERMIT IS — ISSUEO.MY WORKERS'CAMPENSA IDN INSURPNCE CARRIERµ�POUCY NUMBERARE: CONSTRUCTION _ _ j CARRIER____� �,` �.L�l ' PLANREVIEW – --�7� Z POLIGYNUM9ER__ �' . � ELECTRIC (1 ��---� o �c � (IN4SSECTIONNEmNOTBECOMPLFfEDOFTYIEPERWfISFORIXrEF0.N�OREDOOLIJdiS(E7oD�OR 6� � I CERTIFY THAT IN THE PERfORMANCE OF THE WORK FOR WHICH TNIS PERMR IS ISS4EU.I MECHANICAL �j SHALLNo7EMPLOYANYPEF50NINANYMANNER50A570BECAMESUBJECT70THE �� I Uj WORNER9'COMPENSATIONLAWSOfCAL�FORNIA,ANDAGREETHA ISHOULDBECQME INSPECTIONFEE L+ �� = SUBJECS TO 7HE WORKERS'COMPENSATION PqOViSID JS G�SE 3]aa OF iME A - �— "� V' {/ COO ISHA FOR7MWITMCOMPLYWITNTHOSEPR I101 . � ISSUANCE � 1 SMIP p DATE:_ 1� APPLICANT: �_ -- —' w ENER�Y P/C J WARNING FAILURE TO SECURE WORKERS'GOMPEN5ATION CAYEflAGE IS UNLAWFUL,ANO SHALL6E —� :�rY� ;��'�•��, — � SU&IECTpNEMPl.OYERTOCRIMINA�PENALT�ESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ��� ` ODLLlRS(i100,000),IN PDDI710N T�THF COST�F COMPENSATION,DAAIAGES AS PROYIOE�FOfl IN --'-�'T���-�:+' J SECTIDN 370fi OF THE LABOR GODE.IN7EFiE5T.ANDATTORNEY'S FEES. FETENTION FEE: � a CONSTFiUCTIONLENDINGAGENCY PRE-ALTFEE: _ � IHEREBVAFFIFMUNOERPENALTYDFPEflJURYTHATTHEflE1SACAN3TRUCTIONLENDINOAGENCY _ _ � F_�R�, FOq7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.�. W —'_' __ � LENOER'S NAME____ ---- ___ I_- LEN�ER'SA�OflE55__,� ___ -__ --- � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETNRTTHEABOVEINFOfiMATIONISCORRECT. IOTAL FEES 2� � G W I AGREE TO COMPLY WITH ALL GITY AND COUNTY OR�INMlCES WiD 9TATE UWS RELATING TO BUILDINQ � CONSTpUGSIpN,ANDHEREBVAUTHOFliZEREPRESENTA11VE50FTNI5CDUNTv70EN7ERi170N7HE ZABOVE�MENTIONED Pp�PENTV FOR INSPECTION PURPOSES. COMMENTS __ - � Zk �`Iaf l-`1/ �' - QPER TT E N E INn /_ /�`-��/y _ Cn L'�y(-- K�! V � ] RECPT.N n � ' � SI NATUREOF ERMI'REE DATE � � PAID BY - VAIJDATlO _ WHiTE—Deparlment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOL�ENROD--FIe Copy,GREEN—ApplicanPs Copy � ;. �. �.�...�_ i . _ � ..... - , __ _ . .._ �- .. _ ..i, i � �� ^ ! � I � ��� � ! I � I � � j ! 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