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HomeMy WebLinkAbout12759 (13) 1� CITY OF DIAMOND BAR ,�,. — DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ' _ _ w . 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 ' � �` PRESS ''9�' � BUILDIlVG PERMIT APPLICATION � FIRMLY QJOBSITE ,r�'`a�'" �:�„����� ,/�_�� ��r pATEICATION •� PERMIT 2 � P/C ¢ ADDRESS ,a ,7� 1� NUMBER # � ISSUE TYPE OCC °O APN LOT TRACT DATE CONST. GROUP p OWNER �����M `�O9-.,:�nf¢ C�— p ADDRESS �� rc�a pD ��^�t7uJ ��_���'�er ZONING SETBACKS Z CITY�;�•yv��a,elD �k'ZIP EL.� FRONT RW ❑ g APPLICANT ��g�1^i C"o rv S t•ic� �p-�&�}S REAR � ¢ SIDE/SIDE STREET RW ❑ � CONTRACTOR P e�v+ SIDE � ADDRESS � -p A f w" � CITY �1-- ZIP�� TEL.��D f:��� PROPOSED USE o ARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. a ADDRESS � CI7Y ZIP TEL. UNITS STORIES BEDROOMS � v� DESCRIPTION SQ.FT. FACTOR PSP ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER�ENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CON1FiACTORS L4 GaragelCarport W� CENSEUIWFORTHEFIX.LOWINGREASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYCINOR (n � COUNTYN7iICHRE9U1RE9APERMITTOCONSTRUGT,ALTER,IMPROVE,DEMOlJSN,OflREPAIRANYSTqUG W PdtlO/DBCI( w NRE,PRIOR TO ITS ISSUANCE,AL50 RECIUIRES THE APPLICANT FOR SUCH PERMIT TD FILE A SIGNED W � STAiEFENT THAT HE OR SHE IS LICENSEO PUHSUANT TO iHE PROVISIONS OF THE CANTRACTORS LI- � � CENSE LAW(GMAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINE55 AND PRO- POOVSp2 FESSIONSOODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTNEBASISFORTHEALLEGEDEXEMP- (� V TION.ANYVIOLhTIONOFSECT10N7031.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof F 'A CML PENALiY OF N�T MORE THAN FNE HUNDRED DOLLApS(5500).): � ❑I,ASOWNEROFTHEPHOPEH7Y,ORMVEMPLOYEESWI7HWAGESASTHEIASOLECOMPENSATION, � COfi1f118fCldl -� WILL DO THE WORK,AND THE STRUCTURE IS NOS INTENDE�OR OFFEREO FOR SALE(3EC.7044,BUSI- J � NESS AND PROFESSIONS CADE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � Pf10PEiiTY WHO BUILDS OR IMPROVES 7HEREON,AND WHO DOES Sl1CH WORK HIMSELF OR HERSELF OH W THROUGH HIS OR HEH OWN EMPIOYEES,PROVIDE�THAT SUCH IMPROVEMENTS ARE NOT INTENOED OR m . , � ,OFFEflEDWRSqLEIFHOWEVERTMEBULDINGOflIMPROVEMENTISSIXDWITHINONEYEAROFCOMPLE- � 'TpN,THE OWNEfl$UILDER WILL HAVE THE BURDEN OF PROVING THAT HE Ofi SHE DID NOT BUILD OR = IMPF�VE FOR THE PUHPOSE OF SItLE). W ❑I,ASONMEROFTHEPROPERTV,AMEX0.USIVELYCONTRACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.7a44,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81113fI0� ADJ.AREA � W CENSEUWDOESNOTAPPLVTOANOWNEROFAPflOPEpNWHOBUILDSORIMPROVESTHEREON,AND = WHOCONTAACTSFOflSUCHPFqJECTSWITFlACANTRACTOfl(S�LICENSEDPUflSUANTTOTHECANTRAG FEE � ~ TORSLICENSEI,AW.). � DUANTITY DESCRIPTION Y � ❑I AM DIEMPT UNDEH SEC. B.&P.0.FOH THIS REASON � 3 � DATE OWNER � W � LICENSED CONTRACTORS DECLARATION -� � I HEREBV AFFIRM UN�ER PENAL7Y OF PERJURV THAT I AM 1lCENSE�UNDEH PflOVI510N5OF CHAPTER � �v ' p_ 9(COMMENCINO WI7H SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z d Z�+�� �, Y+! X MY LICENSE IS IN FULL FORCE AND EFPECT. P m !` C � LICENSE CU155 „�� LIG.NO._, - ` `': f"� �� ��. J V DATE ���°,�f G'' GONTRACTOR �W i WORKERS'GOMPENSATION DECLAHAl10N r�{^Y�1. � I�l t � i HFAEBY AFFIRM�NDEfi PENALTY OF PERJURV ONE OF THE FOLLOWING DECLAPATIOI��S: � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' �� COMPENSATION,ASPROVIDEDBYSECTION370oOFTHELA80RCODE,FORTHEFERFORMANCE Q OF THE WDRK FOR WHICH THIS PERMIT IS ISSUEO. � � F _I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION Q 37000FTHELABORCODE,FORTMEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS J ISSUED.MY WORKERS'COMPENSATION INSURANCE CARR!ER AND POLICY NUMBEfiARE: CONSTRUCTION } CARRIER PLAN REVIEW Z POIICYNUMBER E Q 0 (THSSECTIONNE�NOTBEWPAPLEfE00FhEPERlMISFOROPEHl/NDRmDOLLARS(51a0)oRLE55) L�Uff4�BIN�v"' +' Z ICERTIF1'THATINTHEPERWRMANCEOFTHEWORKFORWHICHTHISPEAMITI5ISSUED,1 MECHANICAL CS SHALL NOT EMPLOY PNY PEFiSON IN ANY MANNER SOAS TO BECOME SUBJECT TO hIE � WORKERS'COMPENSATIONLAWSOFCALIFORNIqANDAGREETHATIFISHOULDeECOME INSPECTIONFEE F SU&IECTiOTHEWORKERS'C9MPENSATIONPqOVIS10NSOFSECTION37DaOFTHELABOR � CODE,ISHALLFOqTHWITHCOMPLVWITHTHOSEP SION� OSSUANCE D 0 p DATE: r�� APPLIGANT. _ SMIP J WARNWG FAILURE TO SECUPE VJORKERS'COMPENS0.TION COVERAGE IS UNIAWFUL,AND SHALLBE ENERGY P/C � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCMLFMESUPTOONEHUNDREDTHOUSAN� ENERGYPERMIT +CITY � DOLI.ARS(Si 00,000),IN AODITION TO THE COST OF COMPENSATbN,DAMAOES AS PROVIDEO FOR IN A��7�j� 9ECTIDN 37080F THE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: dU V IL+� OCONSTRUCTION LENDiNG AGENCY PRE-ALT FEE: � 1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THATTHERE IS A CONSTRUCTION LENDING AGENCY � PoRTHE PERFORMANCE OF T�OflK FOfl WHICH THIS PERMIT IS ISSUED(SEC.3097,CIY.G�. . W � � LENDER'SNAME ,_ ' ' . 1— LENDER'SADDRESS � � �Ai� TOT L FEES " W ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATEiHATTHEABOVEINFORMATIONISCORRECT. - - - -� � I AOREE TO CAMPLV W1TH ALL CITY AND COIINTY ORDINANCES AND STATE LAWS RELATING TO BUILOING �� � CONSTRUCTION,AND HEREBYAUTHORIZE REPRESENTATIVES OFTHIS COUNTYTO EMER UPON THE � ZABOVE-MENTIONED PROPER7Y FOF INSPEGTqN PURPOSES. h, COM ENT� J 0 y A _ ^�'�' t ! �� m PERMITTEE RINn ' p � R /�" ��� � SIGNAT E P EE DATE = RECPT.NO. 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