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HomeMy WebLinkAbout10031 - CITY OF DIAMOND BAR COMMUNITY DEVELUPMENT DEYARTMENT 21660 E.Copley Drive Suite 190 �T PRES•S (909)860-3195 Fax(909}861-3117 '""" BUILDING PEItMTT APPLIC.4TION FIRMLY � JOBSITE L /�" �" APPLICATION PERMIT � P/C � o ADDRESS ��C�`-� �� ������� DATE______(��_NUMBER ��� # c� ISSUE ' � TYPE OCC -- APN LOT TRACT DATE CONST. GROUP °C OWNER v+�- �� O ADDRESS :7 ��47 C� 1�'t9�"T` I''r-N°�, ZONING SETBACKS z CITY ��_IAtiJ6�1/�t"NY"'tZIP TEL. ��/'Z�Si� FRONT RW ❑ � APPLICANT IAS��re�"i' TEL.rQ'lfs'�'��3�.77 REAR ❑ � SIDE/51DE STREET RW ❑ � CONTRAC7 � �����������'-`7`�e� SIDE _- ❑ � AD�RESS,� � �' /'d.�C:L:.. S''0 ,T'r0 �� � CIN "T.� ZIP �/'.sGG TEL.P'l�.�Z7'�"3�'7� PRaPOSED USE o ARCH/ENG/ �- z DE5IGNER NO.DWEL. Q NO. NO. �/' � ADDRESS UNiTS 1 STORIES � BEDROOMS / � CITY ZIP TEL. � DESCRIPTION SQ.fT. FACTOR PSF ADJ.AREANALWATION � OWNER-BCILDER DEC4ARATION SFR/ADD/REM ', O 0 1 HEREBY AFFIRM 11NDER PENAL7Y OF PERJURY l'HAT I AM EXEMPT FROM THE CONTRACTORS U• GBIBtJB/CatTJOIi � � W CENSELAWFORTHEFOLLOWINGREASONiSEC.7031.5BUSMESSANDPROFESSIONSCODE:ANYCITYOR (/' - U -COUNTYWHICHflE�UIqESAPERMITTOCONSTRUCT,ALTEfl.IMPROVE.DEMOLISH,ORREPAIRANYSTRUG W Patio/Deck � w 7URE,PRIOH i0 ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SICiNEO W . � STATEMENT THA7 HE OR 5HE IS LIGENSEU PURSUANT TO 7HE PHOV1510NS OF THE CONTRACNRS LI- � _ � CENSE�NW(CHAPTER 9(COMMENC�Nd WITH SEC710N 7000)OF DIVISION 3 OFTHE B1151NESSAND PRO- u" POOUSp2 o FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFflOMANDTHEBA515FORiHEALLE6E0EXEMP- V TION.ANYVIOLATIONOFSECTION7037.5BYANYAPPLICANTFORAPERMITSU9JECTSTHEAPPUCANTTO� Z R8-ROO( � A CIVII PENALTY OF NOT MORE THAN FIVE HUNDRED DOlLARS(5600).}: 0 ❑I,ASOWNEROFTHEPFiOPERTY,ORMVEMPLOVEESWITHWAGESASTNEIRSO4ECOMPENSATION, �. COrtIm8fCl81 Z WIIL DO THE WORK AND THE STRl1CTURE IS NOT WTENDED OR OFFERED FOR SALE(SEC.7UdA,BUSI- J _ � NE33 AND PROFESSIONS CODE:THE CONTFACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PilOPEATY WHO BUILDS OR IMPpOVESTHEREON,AND WHO UOES SUCH WORK HIMSELF OR HERSELF OH � CC THROUDHHI90flHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE00F1 m - OOFFEREDFOPSALE.IFHOWEVER,7NEBl11LDMGOflIMPROVEAAENTISSOLDWITHINONEYEAROFCOMPLE � Z TION,THE OWNER-BUILDER WILL HAVE THE BUR�EN OF PR���NG THAT FIE aR SHE OID NOT BUILD OR . � IMPROVEFORTHEPUqPOSEOFSAI�. . ❑i,AS OWNEROF THE PROPERTY,AM EXCIUSIVELY CON7RACTING VWTH LICENSE�CANTRAGTORS -� TO CONSTRUCT THE PROJECT(SEC.704d,BUSINESS ANO PROFESSIONS CODE:THE CONTflACTOHS LI- V2IU8410f1 ADJ.AREA � W CENSE lAW�OES NOTAPPLY TO AN OWNEfl OF A PflOPERT`f WHO BUN.DS OR IMPpOVES THEREON,AND � WHOCONTRACTSFORSl1CHPROJECTSWITHACc]NTflACTOR(S)LICENSEDPURSUANTTOTHECONTPAC- QUANTITY DESCRIPTION - - FEE�"�� . � TORS UCENSE UW.�. � ❑1 AM EXEMPT UNDER SEC. B.d P.Q FOR THIS REASON � \ o ' U LL � � Z DATE - OWNEH W H �U �, � LICENSED CONTRACTORS DECLARATION W � � I MEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNOER PROVISIONS OFCHAPTER ' i d 9(COMMENCINGW�THSECTION7oo0)OFDIVISION30FTHEBL1SiNESSpNOPROFESSIONSCODE,AND z �r. -I- X MYLICENSE IS IN FULL FORCEAND EFFECT. , � LICENSE�C7LrAS/g �/✓ . LIC.NO. ������ j v DATE Q?(��J��7 CONTPACTOA -� ��S�Ge/7'L T- . .a. W r - �i'; � � - WORKERS'COMPENSATION DECLARATION �� � Q _ � � . U � � IiiERE9VAFFIflMUNDERPENALNOFPEflJURYONEOFTHEFOLLOWINGDEC6ARATIONS: " � � Z � OZ _IHAVEANOWIIIMMNTA1NAl'.ERTiFIGATEOFCANSENTTOSELFdNSUFlFFORWORKER5 = � COMPENSRTION,AS PHOVIDED BV SECTION 370o OF THE LABOR CODE,FOR THE PERFOHMANCE U � ¢ OFTHE WOqK FOR WHICH THIS PERMIT IS ISSl1E0. � ' � 1 HAVE AND WILL MAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REQUIRED BY SECPION ' ¢ 37oa OF THE LA90R CADE,FOpTHE PERFORMANCE OFTHE WOFK FOR WHICHTHIS PERMITIS � ISSUF�.MY WORKEFS�'COMPENSATION INSUflANC GARRIER AND POLICV NUMBERARE: CONSTRUCTION y CARRIEH •/ � � PLANREVIEW , � POLICV NUMBEP 0 � , ELECTRIC Z Q Q (IHISSEGTILWNEEANOTBENMFLE7EOOF7FIEPERMlJlSFORONEHUNDRED (SI00)OR PLUMBING Z t CERTIfY THAT IN THE PEPFOFIMANCE OF THE WORK FOR WHICH iHIS PERMIT IS SSUED,I MECHANICAL (J SHALL NOT EMPLOY ANY PERSON IN ANV MANNEfl SO AS T ECOME SUBJEG THE � � WOflKERS'COMPENSATION LAWS OF CAUFORNIA,ANO EE THAT IF I S� BE(X1ME INSPECTION FEE - SUBJEC7TOTkEWORKERS'COMPENSATIONPROVI OF ECT OFTHELABOR ' I � CODE, HALL OR7HWITHCOMPLYWITHTHOS OSSUANCE I / � 0 ry -� p DATE:J ? APPLICANT: s��P � - ENERGY P/C � � � WARNING FAILLIHE TO SECURE WORKEFS'COMPENSATION fAVER E IS UNL'hWFUL,AND SHALLOE � SU&IECTANEMPLOYERTOCRIMINALPENAITIESAN�CIVILFMESUPTOONEHUNDFIEDTHOUSAND EN�RGYPERMIT �4 � � a � DOLLARS(5100,OOo�.INADDITIONTOTHECOSTOFCOMPENSAT10N,0Ah1AGE5ASPROYl0E0FORIN ��. J SECTION37o80FTHELABOflCODE,IN7ERESi,ANDATfOflNE1"SFEES. - RETENTIONFEE: ' � - a - CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � O 0. I HEREBV AFFIPM UNDER PENALTV OF PERJUHV THATTHERE IS ACONSTqUCTION LENDINO AGENCY ' - FOR THE PERWRMANCE OF THE WORK FOR WHICH THIS PEflMITIS ISSUED�SEG 3097,CIV.C.), W � � LEN�ER'S NAME �,� ����� H LENDER'S ADDHE55 . � ICEflTIFYTHATIHAVEREADTHISAPPLICAiIIXJANDSTATETHATTHEA80VEINFOHMA710NISCOPRECT. TOTAL FEES � - � � w I AGREE TO COMPIY WITH Al�CITY AND CAUNN OROIPIANCES AN�STATE LAWS RELATNJG 70 BUILDING � ' � - � CONSYRUCTION.ANDHEfl�VAUiHORIZEREPRESEN7ATIVE50FTHI5COUNTYTOENTERUPON7HE . � .� - � FBOVE-MENTIONED PROPERTY FOR INSPECiION PURPOSES. COMMENTS � +C� (J 'C ii. 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