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Home My WebLink About15301 (20) Y J� \ _ _!�_ CITY OF DIAMOND BAR � , DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES 21660 B.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 PRESS �� BiJII.DING PERI�IIT APPLICATION FIRMLY � JOBSITE �7 T APPLICATI PERMIT / P/C o ADDRESS 2G 2�U C� DATE � NUMBER D! # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER O 'i ZONING SETBACKS W ADDRESS � FRONT RW O � CITY �'IP TEL. REAR ❑ APPiICANT � � TEL� - SI�E/SIDE STREET RW ❑ � CONTRACTOR C� ' %sri TD� E � � C�D�D�RES � G E _ _ P OSED USE � � ARC G/ /�/1°iy- ' � •- � DESIGNER NO.DWEL. NO. . ADDRESS UNITS STORIES _�BEDROOMS � CITY ZIP TEL. � DESCRIPTION S�.Ff. FACTOR PSF ADJ.AREANALUATI�N � Q OWNER-BUILDER DECLAHATION SFR/ADD/REM � I HEREBYAFFlRM UHDER PENALTY OF PEiWFV THAT i AM EXEMPT FROM THE CONTMCTORS LI- G8189B/CBfPOfI l{1 CENSEUWFORTHEFOLLOWINGREA.AN(SEC.7a31.5BU51NE5SAN�PROFE551ON5WDE:ANVCITYOR (n �7 OOUMVNMItlfi1E0UIliESAPERMRTOCONSTRUCT.ALTERIMPROYE.DEMOlISH.ORREPAIRANYSTRUC- W Pe�lo/D6Gk �ZnqE,pqqq 7p�7g�SSUANCE,/�LSO qEWIqES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W � $TATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS LI- CENSE L�W(CHAP�ER 0(COMMENCINO WITH SECTION 7000)Oi DIVISpN 9 OF THE BUSINESS M10 PRO- � POOUSpB FE39qN3 COOEj OflTHAT HE OF SHE IS EXEMPTTiEREFFiOM AND 7HE BA515 FOR TMEALLEdED EXEMP- 7pN,AKVVKKATIONOFSECTION7o3�.58YANV�PPLICANTFORAPEfiMITSU&IECTSTHEAPPLICANTTO Z Re-Roof S � A CML PENALTY OF NOT MORE 7/4W FNE MUNOREO�OLURS(SSaO�.�: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWI7MWAGESAS7HEIasOLECOMPEN5A71ON, � CommerCiel WILL OD THE WORK AND THE STRUC7URE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70M,BUSI- J NE55 AND PROFESSIONS CODE:THE CONTMC70R5 LICENSE UW DOES NOTAPPLY TO AN OWNER OF N PiqPER7YMh10BUNDSORMIPROVESTHEREON,ANDNMOU0E5SUCHWOHKHIMSELFORHERSELFOR � Q hliqUGHHISdiMEROMMEMVLOVEES,PpOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE00R m � OFFERED�ORS/VLEIF,HOWEVERTMEBURDINOOflIMPROVEMENTIS50lDWITHiNONEYEAROFCOMPLE- Z TION,THE OWNER�BUILDER NALL HAVE THE OURDEN OF PROVINO 7Fi�T HE OR SHE DID NOT BUILD OR � IMPROYE FOH TME PUNPDSE OF SALE). w ❑I,ASOMMEROF1HEPfiOPERTY,M1EXClU51YEL�COMMGTINOWfTMUCENSEDWNTMCTOR3 � Q TO CONSTRUCT THE PRO.IECT(SEC.70H,9USINE55 ANO PflOFES510N5 COOE:THE COPlrRACTORS LI- V9IU8UOfl ADJ.AREA W CENSEUWDOESNOTMPLYTOANOWNEROFAPROPERTYNRIOBUILDSOFIMPXOVES7MEREON,AN� � NM1IOCONTMCTSFORSUCHPH0.1EC75WITHACONfRACTOR(SIUCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TO0.SUCENSELAW.). J ^ OIAME%EMPTUNDERSEC. B.BP.C.FORTHISREASON U � S � � DATE OWNER �' � W � LICENSED CONTRACTORS DEGLARATION � � w I HEREBYAFFIRM UNDER PENALTY OF CE0.IURV THAT I AM LICENSE�UNDER PROVISIONS OF CHAPTER � d Y(COMMENCINO 4ATH SECTKKJ 7000)OF OIVISKKJ 30F THE BUSINESS AND VROFESSIONS CADE,AND Z X MY LICENSE LS IN NLL WHCEAND EFFECT. m LL! � 0 LICENSE CLASS � LIC.NO. , J V DATE�.g� �� CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION� � �� U � I HEREBY AFflRM UNDER PENALTY OF PEfUURY ONE OF THE f-0LLOWINO DECLAMTIO : � Z Q 0 I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' 2 � COMPENSATION,ASPROVIOEDBVSEC710N37ooOFTHEIABORC�DE.FORTHEPERWRMANCE W OF THE WORK FDR WMICH THIS PERMIT IS ISSUED. � � ,I HAVE ANO WILL MAIMAIN WOPo(ERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION � Q 970o OF 7HE tABOR COUE.FOR THE PERFORMPNCE OF THE WORK FOR WHiCH 7HI5 PERMIT IS � 0 ISSUED.MV WORKERS' PENSAT INSURMICE CARRIERANO POLIC NUMBERARE� CONSTRUCTION jc,wRiER PLAN REVIEW ( ZaaicY NUMBER ELECTRIC et � �nssEciqrrr��NoreE�iIDOFnfaEw.rrxr�or�taroaEo i )on 1 PLI�MBING Z I CEFiTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS VERMIT IS ISSUED,I MECHANICAL � (3 SHALL NOT EMPLOV M!Y PERSON iN M1Y MANNER SO AS TO BECAME SV&IECT TO THE �, � WORKERS'COMPENSATION UWS Of CALIFORNIq AND�dREE THAT IF I SFKKILD BECOME INSPECTION FEE S SU&IEGT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION]]OOOF THE LABOR CODE,I SHALL FORTMMTH COMPLY WITHTHOSE PHOVISIONS. ISSUANCE � . 7 p DA7E: � � •D�APVLICANT: � , SMIP IIJ 1�� fl w ENERGY P/C `� � /� J WARNIN(3:FAILURE TO SECURE MlORKERS'COMPENSATION CAVEf1AGE IS UNU L,AND SHALLBE /1� � SU&IECTIWEMPLOYEHTOCRiMINALPENALTIESANOCIVILFINESUPTOONEMUNDREDTMOUSAND ENERGYPERFLLIlT DOLURS(t100,000),IN ADDITION TO THE COST OF COMPENSATION,DMIAGES AS PROVIOED FOR IN � SECTION 3708 OFTHE LABOR CODE,INTERE57,M10 ATTORNEY'S FEES. RETENTION F�TT T7T�Tr A 7T1 C A 1 � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � INEREBVAFflRMUNDEHPENALNOFPERJURYTHATTHERE15ACAN5TRUCTIONLEN�INGAOENCY F-0R THE PERFORMMlCE OF THE WORN W R WHICH THIS PERMIT IS ISSUEO(SEC.Joe�,CIV.C.). Z W � LENDER'S NAME � LENOER'S ADDRESS � 1 CEHTIFV THAT I HAVE READ THIS APPLICATIONAND STAiE TMI�T TME NBOVE MFORMATION IS COHRECT. TOTAL FE ES (� �� . �� /� W I AGREE TO COMPLY NATM ALL qTV AND COUNTV ORDINANCES AND STATE UWS REIATING TO BUILOING � � CONSTRUCTION.M1D HEREBV AUT110RIZE REPRESENTRTIVES OF THIS CWNTV TO ENTER UPDN THE Z ABOVE�MEHTIONEDPROPERTYFORINSPECTIONPURPOSES. COMMENTS ��'� � ��f�� 0 � l � PERMITTEE NAME(P Hn 7� (,/) � � `!/� � SIGNATURE OF PERMI EE DA E � RECPT.NO. 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