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HomeMy WebLinkAbout12061 (11) ' CITY OF DIAMOND BAR � `-"--�� DEPARTMENT OF COMMUNITY V OPMENT RVI S '�k�II��D _ � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 Q c j• a 3 pP�R.ESS ���'��'��' BUILDING PERIVIIT APPLICATIO __ 1t�F[MLY o� JOBSITE //��+�, � �, �^j���� �,d� APPLICATION � PERMIT �/y�� � P/C ADDRESS �� � tl �� DATE NUMBER �� # $ 15SUE i r� �` TYPE OCC APN LOT TRACT DATE � CONST. GROUP °C OWNER � ' � L� pADDR SS � I '. ZONING SETBACKS Z CITY ZIP TEL. REART RW ❑ g APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACT Q I .`�L ( � SIDE ❑ ¢ CDDRESS ZIP� �TEL. PROPOSED USE O 0 ARCH/ENG/ z OESIGNER w NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O p 1 HERE9Y AFFlRM UNDEF PENAIT!OF PERJURY THAT I AM EXEMPT FHOM THE CONTRACTORS LI- � Garage/Caryod � W CENSEUWFORTHEWILOWINGHEASON(SEG�o31.5BUSINESSANDPROFESSqNSCODE:ANVCITYOR V COUNTYNMICHREGUIRE9APEFlMITTOCONSTRUCT,ALTER,IMPROYE,DEMOLIBH,ORREPAIRANYSTRUG W P8110IDBCk ' W TURE,PRIOR TO ITS ISSUIWCE,PL50 HE�UIRES 7ME APPLICANT FOR SUCH PERMIT TO FILE A SIONED w ' STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF 7HE CONTRAC70R5 LI- � CENSE LAW(CHAPTEfi 9(COMMENdNG WITH SECTION 700D)OF DNI6ION 3 0F THE BUSINESS AND PR0- �' POOVSPB � PESSpNSO00E�ORTHA7HEOR5HE15EXEMP7THEREFROMANDTHE6A515FOHTHEALLE6EDEXEMP- (' V TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO z Re-Root F, AqVILPENALTVOFNO7MOfiETHANFIVEHUNDREDDMLARS(65oo).): � ❑I,ASOWNEROFTHEPPOPEHTY,ORMYEMPLOYEESWI7HWAGESASTHEIRSOLECAMPENSATION, � COmRIBfCIaI � WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(5EC.7064,Bl1Sl- J N NE33 AND PfiOFE5510NS CODE:THE CONTRACTOHS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ? . PF�PER'fYNM1IOBUILD30R1AiPROVE3THEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOp � TliROUGH HIS OH HER ONM EMPLOYEES,PROVIOED THAT SUCH IMPHOVEMENTS ARE NOT INTENOED OR m � ,OFFEHEDWRSALEIF,FIOWEVER,THE&11LDINGORIMPROVEIAENTISSOLDWITHINONEVEAROFCAMPLE- Z 'TION,THE OWNER�9UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR = IMPROVE FOR7HE PURPOSE OF SALE). �y ❑I,ASONMEROFTHEPHOPERiY,IUAEXCLUSIVELYCONTRAC7INGWI7HLICENSE�CONTRACTOR3 � TO CONSTRUCT THE PROJECT(SEC.1014,BUSINESS AND PROFESSIONS COOE:THE CONTRACTORS LI- V8IU8flOf1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEHOFAPROPERTYWHOBUIL�SORIMPROVESTHEREON,AND — � MhI00�NTRACTSFOflSUCHPR0.IECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE � TOHSl10ENSELAW.�. � ❑111M EXEMPT UNDEFi SEC. B.&P.C.FOR THIS REASON � � V � ¢ DATE OWNER U Z W Q LICENSED CONTRACTORS DECLARATION W � I HEREBV AFFIRM UNDEfl PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS 0F CHAPTER � ' p� 6(COMAIENqNfiWITHSECTION7o00)OFDIY�SION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z X My UCENSE IS IN FULL FORCE AND EFFECT. �n � m 0 UCENSE SS �' �� LIC.NO. t,L- J- � U �ATE � CONTRACTOH� a W � - WORKERS'COMPENSATION DECLARATION ¢ �^l�, k� � I HEREBYAFFIRM UNDEH PENALTY OF PERJURY ONEOFTHE FOLLOWMG DECLARATIONS: Z � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORNERS' _ COMPENSATION,ASPROVIDEDBVSECTION3/o00FTHELABORCODE,FORTHEPERFORMANCE U Q OF THE WORK FOR WHICH TWS PEHMIT IS ISSUED. � W 1 HAVEAND WILL MAIMAIN WORKEHS'COMPEN9ATION INSURANCE,AS REQUIRED BY 9ECTION O 37000FTHEIABORCOUE.FORTHEPERWRMANCEOFTHEWORNFORWHICHTHISPERMITIS - ISSUED.MY WORKEAS'COMPENSATIINJ IN�I�RANCE CARRIER AND POLICY NUMBEHARE: CONSTRUCTION Q ,A � caRRIER C�i � _ PLAN REVIEW - � POLICYNl1MeER '9 I� � ELECTRIC � 0 (iHISSECTiONNE�NOTBECOAIPLETmOFTHEPERMTISFORQVEHUN�{iEDWUAAS�S/00)ORLESS). PLUMBING Z I CEHTIFYTHA71N7HE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSl1ED,1 MECHANICAL (J SHALLNOTEMPLOYANYPEflSONINANVMANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSRTION LAWS OF CFLIFORNIA,AN�AGFEETHNT IF I SHOULD BECAME INSPECTION FEE Stl&IECTTO THE WORKEFiS'COMPENSATION PROVISI OF SECTION 37000F THE LABOR /� q/� � E,I6HA THWITiCOMPLYWITH EP,q; ioN � ISSUANCE `�/(JL,/ � SMIP p ,DATE: s APPIICANT. '� I _ _______. � WAANMG:FAILUR[TO SECURE WOFiKERS'CAMPENSATION COVEFAGE IS UNLAWFUL.AND SHALLBE ENERCaY P/C � &UBJECiANEMPLOVERTOCqIMINAIPENALTIESANUCIVILFINESUPTOONEHUNDREOTHOUSAND ENERGYPERMIT DOLLARS(5100,OW),IN ADDITION TOTHE COSTOF COMPENSATION,DAMAGESAS PROVIDE�FOR IN � SECTION37090FTHELABORCOOE,INTEREST,ANDATTORNEI"SFEES ' RETENTIONFEE: � CONSTpUCT10N LENDING AGENCY PHE-ALT FEE: O � i HEflEBYAFFIRM UNOER PENALTY OF PERJURY THATTHERE IS A CONSTRUCl10N LENDING RGENCY FORTHE PERFORMANCE OF THE W�RK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3097,CIV.CJ. Z W � LENDERBNAME - F— LEN�Efl'SMDRESS � TOTAL FEES � . � ICEHTiFYTHATIHAVEREADTHI3APPLICATIONANDSTATETHATTHEABOVEINFORMAlIONISCARRECT. � w IAGREETOCAMPLYWITNALIGT'ANDCOUNTYOFiDINANCE5AND5TATELAWSRELATINGTOBUIL0ING � CANSTRUCTION,AND HEHEBYAUTHORIZE fiEPRESENTATIVES OF THIS COUNTV TO ENTER 11PON THE ' Z ABOVE-MENTIONEO PROPERTY FOR INSPECTION PUNPOSES . COMMENTS � �ct�i� �: _ m PEflM E N M) � � � � SIONA OF PE I EE ATE � - RECPT.NO. 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