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HomeMy WebLinkAbout10331 (5) � `;�'�� '� CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT � .;,�.;� . 2L660 E.Coploy Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 �"""' BUILDINGPERIv1ITAPPLICATION FIRMLY o� JOBSI7'E :"�'��"B�,� ��`�����p�; /��� APPLICATION � �;��� PERMIT � P/C � "��---�' ADDRESS � �9 �• DATE NUMBER # P � ISSUE TYPE , OCC APN LOT TRACT DATE CONST. GROUP °C OWNER ��' O ADDRESS �� "�� ZONING SETBACKS ' z CITY ZIP TEL.�d'Z- C��f�.. FRONT RW "'❑ o APPLICANT �+'� ��°' TEL. �-s'�da_�5d`�!�b S DE/SIDE STREET RW ❑ � CONTRACTOR ���-�''�C'�e� "f�� SIDE ❑ � ADDRESS � " i3 "�'�''� _ ., � CITY �+'�4�...1�,�t-.;7 ZI `�" TEL. PROPOSED USE w ARCH/ENG/ � :' W DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION «� � O OWNER•BCILDER DECLARATION SFR/ADD/REM � p I HEREBV AFFIqM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTOflS Lb G8�890/C9�OIt � W CENSEUWFOR7HEFOLLOWINaREASON(SEC,7o97.66USINESSANDPROFESSIONSCAOE:ANVCITYOR � (n U COUNiYWH�CMREQUIRESAPERMITTOCONSTflUCT,AL7ER,IMPROVE,DEMOLI3H2ORREPAIPANY3TRUC- W pati0/D9Ck � � � w- TURE,PRIOR TO ITS ISSUANCE,AL$O HE�U�RES THE APPLICANT FOR SUCH PEfiM1T TO FILE A SIGNED - � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTqAC70RS LI• �, � CENSE LAW(CHAPTER 8(COMMENCINd WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- LL' PooUSpa _g°�' - ^ FESS�ONSfAOE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALIEGEDEXEMP- . � � TION.ANVVIOLATIONOFSECTION7031.5BVANYAPPLICANTFOHAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Floof � AGIVILPENAL7YOFNOTMORETHANFIVEHUNDREDDOLLAHSCS5oo).): _ �� ❑I,ASOWNEROFTHEPROPEflTV,ORI�IVEMPLOYEESWITHWA0ESA5THEIRSOLECOMPENSATION; '• 0 .CORIl178�CIfl1 Z N7lL DO THE WORK,AN07HE STR11C7URE IS NOT INTENOEO OR OFFERED FOR SALE(SEC.7a44,9USI- ' `J -� NE99 AND PROF€SSIONS CODE:THE CONTRACTOR6 LICENSE LAW D066 NOT APPLV TO AN OWNER OF � ,.•--�a � PqOPERTYWHOBUILD30RIMPROVESTHEREON,ANOWHOPOESSUCHWORKHIMSELFOHHEHSELFOR � m . � TFIROUGHHISORHEROWNEMVLOYEES,PFOVI�E�THATSUCH�MPROVEMENTSARENOTINTENDEDOR � 0 OFFEfiE�FORSPLE.tFHOWEVER,THEBUILDINQORItJPROVEMENTISSOLDWITHINONEYEAFOFCOMPLE- . � TION,THE OWNER-BUILDER WILL,HAVE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIID OR� � IMPRUVEFOpTHEPURPOSEOFSALEJ. -- - -- ❑I,AS OWNER OF THE PROPERTV,AM EXCLU5IVELY CONTRAC7INQ WITH LICENSED CONTRACTORS � Q� TO CONSTHUCT THE PROJEC7(SE0.7o4a,BUSINESS AND PROFE5910N5 CODE THE CONTRACTOHS LI- 81U81iOf1 � DJ.AREA ' W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPFATYWHOBUILDSORIMPROVESTHEREON,AND , � WHOCONTRACTSFORSUCH7ROJECTSWITHACON7RAC70R(5)LICENSE�PURSUANTTOTHECONTRAP QUANTITY DESCRIPTION � FEE ; � TORS LICENSE LAW.). J �' � ❑i AM EXEMPT UNDER SEC. B.8 P.C.FOR TFNS REASON Q � � � � V � - �'L" DATE OWNER V . W � LICENSED CONTRACTORS DECLARATION �y - � 1 HEREBYAFfIPM UNDER PENAITY OF PERJURY 7HFT IAM UCENSED UNDEfi PROVISIONS OF CHAPTER - �- . � 9(COMMENCINO WITH SECTION 7000)OF DIVISION i OF THE BUSINESSAND PROFESSIDNS CADE,AND Z MY LICENSE IS W FULL FOfiCE AND EFFECT. ,�p��.�pa g � � LICEN3E CLA9S ��� -y LIC.NO. °'C°"Z�J��,, �,�t�� � U DATE �""��'S _�� CONTRACTOR��L.�+�'l�(G��°'�����'/.�+^''a � J . . W - .. .-. � . . , � WOpKERS'COMPENSATION DECLARATION �i� � � 1 HEREBV AFFIRM UNDER PENALTV OF PERJURY ONEOFTHE FOLtAWING DECLARATIONS: � V N Q - � _I HAVE AND WILL MAINTAIN A CERTIFICATE Of CONSENTTO SELFINSURE FOR WORKERS' _ Z COMPENSATION,ASPROVIDEDBY9ECTION37ooOFTHEIABOflCODE,FOPTHEPERFORMANCE U ¢ �OFTH�E WORK FOH WHICH THIS PEHMIT IS ISSUED. � W "��I HAVE AND WILL MAINTAIN WORKEHS'COMPENSA710N INSURANCE,AS RE�UIRED 0Y SECTqN Q a7ooOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKWRWHICHTHISPERMITIS ISSUEU.MY WOHKERS'CAMPENSATION INSURANCE CARRIER ANO POLICY NUMBERARE: CONSTRUCTION __ jcnaniEn 'w , � "�"�.�,0-� PLAN REVIEW ��J �, � POLICY NUMBER • a��' �`c �•�� •./ �� ELECTRIC ¢ � ((HISSEC�IONNE�NOTBEOJMPLEfEDOFTHEPEFMTISFORONEHUNDREDDOlLAR9(SIW)ORL�6)� P�UMBING Z..__. ..__, Z 1 CERTIFY THAT IN 7HE PERFOPMANCE OF THE WORK FOR WHICH THIS PERMIT 161SSUED,I MECHANICAL � (,�} 5HALLNOTEMPLOYANYPEfl50NINANYMANNER50A5TOBECOMESUBJECTTOTHE Uj WORKERS'COMPENSATION LAWS OF CALIFOHNIA,AND A6REE THAT�F 1 SHOLII,D BECOME INSPECTION FEE �� _ , SU&IECTTOTY.EWOflKER9'COMPENSATIONPFIOVISION50'rSECTION37ooOFTHEIABOR - CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVI51�N5. � '"--� ��,�,_ '�.:�� i e ,�. p DATE: .� APPIIGANP. � E GY P/C . J WARNIN6:FAIWflE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFIJL,AND SHALL BE �y SU&IECTANEMPIDYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDFEDTHOUSFN� ENERGYPERMIT UDLLAHS(5100,000),�N ADDITION TO THE COSTOF CAMPENSATION,UAMAGES AS PROVIDE�FOR IN � SEC'fION 870B OF THE UBOR CADE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: OCONSTHUCTION LENDINQ AGENCY PRE-ALT FEE: , ` ��'��j _, x� � � 1 HEREBY AFfIRM UNDEH PENALTY OF PERJURY THATTHERE IS ACONSTRUCT�ON LENDING AGENCV - FOR 7HE PER W RMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS5UED(SEG.30W,CIV.C.), , Z W � IENDER'6 NAME � � k— LENDER'SAODFESS . . WICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOHMATIONISCARRECT. TOTAL FEES � `� � , _ � - � IAaREETOCOMPLYWITHALICINANOCOUNTYORDINANCE5AND57ATELAWSRELATW6TOBUILDINO - . CONSTRUCTION,ANO HEREBYAUTHORRE HEPRESENTATIVES OF THIS COUNTYTO ENTER UPON THE - � Z ABOVE�MENTIONED PHOPERTY FOR INSPEC710N PURPOSES. COMMENTS - 0 _ �A� ��t�� m PEHMI7TEE NAME(PRINT) er - - C!J - �,1� � . . � SIGNA7UR P"P. F' /� ,_ DATE . . = RECPT.N . 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