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HomeMy WebLinkAbout14062 1� CITY OF DIAMOND BAR ���� DEPARTMENT OF COMMUNITY&DEVELOPMENT 3ERVICES �__.,' w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ���'� BUQ.DING PERMIT APPLICATION FIRMLY � JOBSITE `��'� /i APPLICATIO •-��._ PERMIT D �jf/C o ADDRESS � V DATE NUMBE # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNEFi MA-Q-L'.��� o A�DRESS - 7/��biJ ZONING SETBACKS w CITY � ZIP TEL. " REORT RW ❑ � APPLICANT TEL.���'-, -� / o SIDEJSIDESTREET RW � CONTRACTOR l�J SIDE ❑ p� ADDRESS 1 � C1TY ZIP TEL. y PROPOSED USE � ARCH/ENG/ DESIGNER NO.DWEL. NO. NO. AD6RESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCFiIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � Q OWNEF-BUIL�ER DECLARATION SFR/ADD/REM O I HEREBY AFFliql UNDER PEWILTY Of PERNRV THAT I AM EXEMCT FROM THE CONTMCTORS Li- G9f0901C9(POh � GENSEUWFORTHEFOLLONINOREASdJ(SEC.7031.6BUSINESSANOPpoFE5510NSCODE:ANYCITVOR (n COUNTYWHIdiREOUIPESAPERMITTOCONSTRUCT,AL7ER.K17ROVE,DEMOLISN,ORFEPAIHANYSTRUG W PatiolDeck 7URE,Vppq ia lTS ISSUANCE,A150 REWIRES THE APPLICANT FOR SUCN PERMIT TO FILE A SIGNEU W � STATEMENT TF41T NE OR SNE IS LICENSED PURSUNJT TO THE PROVISIONS OF TME CONTRACTORS LI• � GENSE UW(CHAPTEfl Y(COMMENCINO W1TM SECTION 7a00)OF DIVISION 30F THE BUSINESS AND PRO- u' POOI/SP8 KESSIONSCODE)ORTHATHEORSHEISE%EMPT7HEREFROMAN�TNEBASISFORTHEALIEQEDEXEMP� (� TqN.ANYVqLATIONOFSECTION7o71.68VANYAPPLICANTFOPAPERMITSU&IECTSTHEAPPUCANTTO Z Re-Root � ACIVIL PENALiY OF NOT MORE THAN FIVE HUN�REO DOLUFS(f5o0).)� � ❑I.ASONTlEHOFTHEPROPER7Y,ORMYEMPLOYEESWITHW/GESAS�MEIRSOLECOMPENSAiION. � C�Ifi111efClfll NALL DO THE WORK AND TYIE STRUCNHE IS NOT IN7ENDE0 OR OFFERED FOR SALE(SEC.70N,BUSI- J � NE55 AND PRpFE9SION5 CODE:iHE CONTRACTONS LICENSE 1.1W DOES NOT APPIV i0 AN OWNER OF ' PIqPERTY WF10 BUILDS OR MIPROVES THEREON,NJD NM1IO DOES SUCH WORK HIMSELF OR HENSEIF OR � THfqUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUtli1MP90VEMENTSARENOTIN7EN0E00R m QOFFENEOFORSALE-IF,FIDWEVER7HEBUILDINGONIMPROVEMENTISSIXDWI7HINONEYEAflOFCO1dPlE- Z TpN.THE ONMEREUILDER WILL M�VE TME BURDEN OF GPOVING THAT HE OR SME DID NOT BURD OH � MIPROVE FOP iHE PURPQSEOF SALE�. W ❑I,ASOVMEROFTHEPROPERIV,AMEX0.USNELVCOMMCTINGWITHLICENSEDCONTMCTORS Q TO CONSTRUCT THE Pi70JECT(SEC.]ON,BUSINESS AND PPOFESSIONS CO�E:THE CONTRACTOHS U- VBIU8tI0f1 ADJ.AREA W CENSEUWWE.3NOTAPVLYTOPNONNEROFA7ROVERTVWNOBIlILD50flIMPROVESTNEREONAND � WHDCONTMGTSFORSUCHPRWECTSWITHAWftiMC70R(5)LICENSEDPURSUANTtOTMECONTMG- QUANTITV DESCRIPTION FEE � TOR8 LICEHSE UW.�. ❑1 AM E%EMP?UNDER SEC._ B.d P.C.FOR THIS REASON Q 3 ` —._ � � � DATE OWNER !__ — U W � LICENSED CONTRACTONS DECLARATION W � I HEqEBYAFFIRM UNDEP PENALTY OF PEflJURY THA7IAM LICENSED UNDER GROVISIONS OF CHAPTER � j i � �(COMMENqNO'MTH SECTKKJ 7oa0�OF DNISION 30F iHE BUSINESS AND PROFFSSIONS COOE,AN0 Z X MY LICENSE IS IN FULL FCRCE AND EFFECT. .�f � m � LICENSE CUSS �3� L iG.NO. �L � / 1 � � V DATE��I b.;T� CONTRACTOR a W � WORKERS'COMPENSATION DECLAFATION a � I HEHEBV AFFIflM UNDIER PENALTY OF PERIURY ONE OF THE WLLOWMG DECL0.RAilONS U C/� a Gl IH�VEANDWILLAUINTAINACERfIFICATEOFCONSENTTOSELF-IN5UaEFOHWORKEHS' _ � COMV SISION,AS FROVIDED BY SF.CTION 3]DOOF TNE 1R60H CO�E.FOH THE PEfiFOHMANCE �U OF WORK FOR WNICH iHIS oERM1T IS ISSUEO. � W __I HAVE AND WILL MAINTRIN WORKERS'GOMFENSFTION INSUFANCE.AS REOl11RE�BY SEGTION Q 3700 OF THE IA90R CCAE.FOR THE VERFOfi4ANCE OF THE WOHK FOR WHICM iH15 PEHMIT IS ISSUED.MYWOfiKERSCO�MPE./NS7ATqNI UHAN^CECARPIEHANDP�L',CYNUMOERARE�. CONSTRUCTION _ yCAPFlIEH �n LJ/PA� G1 PLAN REVIEW — —�---� —�—�---.—i. � PaicvnuMeER_�o)/,�_I�4�7� �� ELECTFIC � �rr�ssEcrorir��NoreEcn�wifrmc�n�pEpixr�sroaonE�n,roae000unrsfs�wlon�ss). PLUMBING ZI CERTIFY THAT IN T11E PEpFORMANGE OF THE VJORK FOq WHIGH TNIS PERMIT IS ISSUED,l MECHANICAL �'� � ��� � `' (,'J SHALLNOTEMPLOYqNYPER50NINANYMANNER50A5TOBECOME$ll&IECTTOTHE " " - -�..r � WORKEfiS'COMPENSATpNUW50FCALIFORNIA,AND�GREETHATIFISHOUIDBECOME INSPECTIONFEE SU&lEC OTHE RKERS'CQUPENS/.TIONPROVISIONSOFSECTION3]ODOFTHEIABOR �ySUANCE H F WITN COMPLv WI SE PROVISIDNS. ��— p �ATE: � !� L�APPLICANT: SMIP ' � ENE J WMNINC:FAILUflE TO SECURE WORKERS'COMPENSATION CAVEflAGE IS UNLAWFIIL,AN�SNALL BE i _ . �y SU&lEC7ANEMPLOYERTOGPIMINAIPENALTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT - -�� DOLURS�f1oo.00o),INPDDITIONTOTHECOSTOFfAMPENSATION,DAM�GE9ASPfiOVIDEDFORIN —��-'r�+-- - � SEGTION3]OBOFTHELABORCODE.INTEREST,ANDATTORNEY5FEE5. RETENTIONFEE: �� d GONSTRUCTION LENDING AGENCY PRE-ALT FEE � INEREBYAFFIRMUNOERGENPI7YOFPERJURVTHATTHEREISACONSTRUCTIONIENDINGAGENCV n- FOR THE 7ERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oW,CIV CJ- � Z W � LENOER'S NAAIE _—__. _` F� LENDEflSADORE55 �_ � � ICEflTIFY7HATINMEREA�TNISAPPLICATIONlJJ�STATETHATTNEABOVEINFORMATIONISCORRECT TOTAL FEES � IAGREE TO COAIPLV WITH ALL CITV AND CWNTYORDINANCES ANO STATE LAWS flELATING TO BUILDING � CONSiRUCTION,AND HEREBYAUTFqRRE REPR ENTRTIVES OF THIS COUNTY TO ENTEfl UPON ME Z ABOVEMENTIONED PROPERTV FOF INSPECTION URPOSES. COMMEI`7T o �g � �v s � � m PERMITT E N E PHINT) - ¢ r � � SIGNATURE RMITTE OATE = FECPT.NO. 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