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HomeMy WebLinkAbout16126 (22) n _ 1�_ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ! � 21660 E.Copley Drive Suite 190 w (909)860-3195 Fax(909)861-3117 PRESS ���'��°� BUII,DING PERMIT APPLICAI'ION � � FIRMLY a� JOBSITE APPUCATION 1 PERMIT P/C ADDRESS_�Z�� C�.�-�s�- 1e�(��,Jl} DATE �"",���( NUMBER q� #� � APN LOT I'?i`++�� TRACT �Z.2 P�'"] DATE CONST. __����d'a,A OCC g OWNER GROUP o ADDRESS e y�U�+f� f'�ttl� ZONING SETBACKS � CITY �l�'1�'_ ZIP �3Lbf2 TEI..�'`L�r���-��Yt! FRONT RW ❑ APPtICANT Se'k,�M�' TEL. SCLi�.4. REAR ❑ z�. SIDE/SIDE STREET RW ❑ � CONTRACTOR * ��i;y1..��' t' SIDE p ADDRESS j.�,�.C3 uRi G:,.�-Iv1�la.. � CITY /'j"V!/1[7. ZIP�1' +i . TEL.9��1=�y 7"�y0 PROPOSED USE_��'�,�+�,�r2,� ARCH/ENG/ �z DESIGNER_�� Fio` _,�"��SC">C .. � ADDRESS NO.OWEL. NO. NO. <n UNITS STORIES BEDROOMS N CITY ZIP J�TELf' - - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•BUILDER DECLARATIDN SFR/ADDlREM O 1 HEREBY AFFlRM UNDER PENALTY OF PERIURY TFIAT I M7 EXEMPT fROM THE CONTRACTORS ll- G8f898/C81�70fI W CENSEIAWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANYCIT/OR (/� Z COUNTYWHICHREIXIIRESAPERMfTTOCONSTRUCT,ALTER,tMPROVE,DEMOUSH,DHREPAIRANYSTRUC- W pafio/D6Ck �j� TURE,PRIOR TO ITS ISSUANCE,Q50 RE�UIRES THE APPIICANT FOR SUCH PERMIT TO fllE A SIGNED W � STATEMENT THAT HE OR SHE IS uCENSED PURSUANT TO THE PROVISIONS OF THE CANTRAC70RS LI- CENSE LAW�CHAPTER 9(CDMAIENCIN�WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSPB FES910NSCODE�ORTHATHEORSHEISEXEMPTTHEREFROIdAN�THEBASISFORTHEALlEOEDE%EMP- (� 7qN.Mh'VIOLATIONOFSECTION7o31.5BVANYAPPLICANTfORAPERMI7SU&lECTSTHEAPPLICANTTO Z Re-Root F A CML PENALTV OF NOT MORE THAN FNE HUNDREO DOLLARS(SSoo)J: � ❑I,ASOWNEROF7HEPFOPERTY,ORMYEMPLOYEESWI7HWAGESASTHEIRSOLECOMPENSATION, O CommOlCI81 -- WILL DO7HE WORK,M!D THE STRUCTURE IS NOT INTENDEp OH OFFERED FOR SALE(SEC.70{4,BUSI- J � NESS AND PROFESSIONS COOE:THE CANiHACTORS LICENSE UlW DOES NOT APPLY TO AN OWNER OF = PROPEHfY Yh10 BUIlD50R IMPROVES THEREON,AN�YAiO DOES SUCH WORK HIMSE�F OH HERSELF OR � THRIXIOH H5 OR HERONM EMPLOYEES,PROVIDE�THAT SUCH IMPROVEMENTS ARE NOT INTENDm OR � OFFERm FOR SALE If,HOWEVER iHE BUIl01NGOR IMPROVEMENT IS SOLD WITHINONE VEAR OF COMPLE- Z TION.THE ONMER�BLIILDER WILL HAYE THE 6tJfl�EN OF PROVINO iHAT ME OR SNE DID NOT BUIIA OR � IMPROVEFORTHEPURPOSEOFSALE�. W ❑I,ASOWNEROFTHEPROPEHTV,IIME%CWSIVELYCONTRACTIN6WITHLICENSEDCONTMCTORS � TO CONSTRUCT TME PRO.IECT(SEC.7W4,BUSME55 AN�PROFESSIONS CDDE:THE CONTHACTORS LI� VHIUBIIOf1 ADJ.AREA W CENSE UW DOES NOTMPLY TO AN OWNER OFAPROPER7Y WHO BUILD9 0R IMPROVES 7HEREON,AND � WHOCONTMGTSFOHSUCHPR0.IECTSWITHACONTRACTOR�S�LICENSEDPURSUAWTTOTHECONTRAG QUANTITY DESCHIPTION FEE � TORSUCENSEIAW.} ❑i AM EREMPT UNDER SEC. B.8 P.Q FOR THIS REASON Q 3 U � ¢ DATE OWNER U � LICENSED CONTRACTORS DECLARATION W � � W 1 HEREBV AFFIRM UNDER PENAI.N OF PEfUURV THAT 1 AM UCENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINpW1T1i5ECTION70oo)OFDIVISION30FTHEBUSINESSAN�PROFESSIONSCODE,ANO Z ��� MY LICENSE IS IN NLL FOflC AND EFFECL m LICENSE CUSS �t F LIC.NO. �.7i +�G1 � U �ATE �"pT''��I CONTRACTOR ��✓ -j!s�=`y�.y�.�___� a l�.l � WORKERS'COMPENSATION DECLARATIUN Q � I HEREBY AFFlRM UNDER PENALTY OF PERJURY ONE OF THE F-0LLAWING DECLARATIONS: Z � _t HAVEAND WILLMAINTAIN ACERTIFICATE OF CANSENTTO SELF-INSURE FOR WORKERS' _ COMPENSATION,AS PROVIpED BY SECTION SToo OF THE IABOR CO�E,FORTHE PERFORMANCE U � OF THE WDRK FOR WHICH THIS PERMIT IS ISSUEO. � � __. iHAVEANDWILiMAIMAINWORKERS'CAMPENSATIONINSl1RANCE,ASREOUIREDBVSECTI�N Od 37a0�THELABORCODE,FORTHEPERFORM�NCEOFTHEWOFKFORWHICHTHISPERM1T15 ISSUED.MY KERS'CLOMPENSATIONINSURANCECpRRiERANDPOUCYNUMBERARE: CONSTRUCTION � GARRIER . "7 . 7 C > .__ j�� ��v� PLAN REVIEW � POLICYNUMBER IL91�P.�/�`�„ . _� � � — ELECTRIC � (IHISSECTqNME�NOT8E00M1RffEDOFhffPELVNTISFOROt�EHIN�DREDDQ.LA0.5(510D)ORLESS� PLUMBING l 1 Z I CERTFY THAT IN THE PEflWRMANCE OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL � ��� („j SHAIL NOT EMPLOYANY PERSON IN ANY MANNEfl SOAS TO BECOME SVBJECT TO THE . . .. . ., .,,;l � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETH0.TIFI5HOULDBECOME INSPECTIONFEE S SV&IECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE UBOR '^�� CADE,I SHALLFORTHWITH COMPLY WI7HT OSE PROVISIONS. ISSUANCE oJJ��� � ./-� �9�,,/�� p DATE:� APPLiCANT: �—_[�.� _�r�� �"/�"- SMIP __ J WMNINO:PAILUFE TO SECURE WOPKERS'COMPENSATION COYERAGE IS UNLAWFUL,AND SHALL BE , ENERGY P!C d^r%' � SU&IECTANEMPIOYERTOCRIMINALPENALTIESANOGIVILFMESUPi00NEHUNDREDTHOUSAND ��-�' '"`"'�"' - DOLLARS(f100.000),INADDITIONTOTNECOSTOFCOMPENSATION,DAMAGESASPROVIDEOFORIN ENERGYPERMIT _�_ ���� � � ���a.':}""� J SECTION 37oe Of THE LABOR CODE,INTEREST,AND ATTpRNEY'S FEES. �j�y.4,Q„�P}y'&.1'�,��x:.'v � RETENTION FEE: OCONSTRUCTION IENDING AGENCY PRE-ALT FEE: � IHEREBYAfFiRMUNDEHPENALTVOFPERJURVTHATTHEtiEISACONSTRUCTIONL'cNDINGAGENCY FOR TME 7ERFORMNtlCE OF THE WORK FOR WHICH TMIS PERMIT IS ISSUED(SEC.3oe],CIV.C.j. 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