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HomeMy WebLinkAbout14123 (16) � A CITY OF DIAMOND BAR �-. ' ��'-- DEPARTMENT OF COMMUNITY&DEVEIAPMENT SERVICSS � , 21660 E.Copley Drive Suite 190 � �� (909)860-3195 Faz(909)861-3117 PRESS � �� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE DATEICATION! ��� 't" ��� NUMBER�` � j Y�J #/C a ADDRESS rr2 F� �l�j..P.T� ,L��,,� �J. (; � S' � 1 $ issue TYPE occ APN LOT_��____ TRACT DATE_ CONST. GROUP °C OWNER G'�- ,L�i�J i''yl� o ADDRESS� 3 �y f'r�-�sirr►t� I'�' ZONING S@TBACKS � CITY�v vYY1-rL..s ZIP �D 3 TEL. FRONT RW ❑_____ APPLICANT TEL. REAR ❑,_ � SIDE/SIDE STREET RW ❑ _ CONTRACTOR d ✓r V S' �[/�., SIDE __ n__.. ¢ ADDRESS� d, PROP�SED USE_ � CIN ��y�_+o?'�� ZIP TEL�y�3--%g" -7S o ARCWENG/ —��( z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS ' STORIES _� BEDROOMS S � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA'iION SFR/ADD/REM p I HEREBY AFFlRM UNDER PENALiV OF PF.RJURY THAT I AA1 EXEMPT FROM THE COMRACTOPS LI- Gaf89BJC31pOfY �y CEMSEIAWFORTFIEFOLLOWINGPEASON(SEC.7031.SBUSINESSANDPROFESSIONSCOUE:ANVCITYOR (n C_) COUNTYWHICHREWIRESAPEFMITTOCONSTRUCT,ALTER,IMPROV£,DEMOLISH,ORREPAIRANYSTRUF W pali0/DBCk C 7UFiE,PRIOR TO ITS 155111WCE,ALSO REQl11RES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEU V� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI� � � CENSE LAW�CHA7TEA B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSMESS AND Pfl0- LL POOUSpB FES5pN5CODE)ORTHATHEORSNEISF.%EMPT1HEflEFROMANDTFIEBA313FORTHEALlEGEOEXEMP� � TION.ANYVqIATIONOFSECTION7031.58VANYAPPIJCANTFORAPEPMITSU&1EC75THEAPPLICANTTO � pe-Roof A CIVIL PENALTY OF NOT MOHE TNAN FIVE HUNDRE�DOLLARS�5500).): - ❑I,AS OWNEH OF THE PROPER7Y,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, Z � Gommercial � YALL DO THE WORK AND THE STHl1CTURE IS NOT INTEN�E�OR OFFERED FOH SALE(SEC.7044,BU51- _I � NE99 AND PROFES9�ONS CODE:THE CONTRACTORS LICENSE lAW DOES NOT APPLV TO AN OWNER OF J PFlOPEHN WFIO BUIIDS Oq tMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR � p[ TMqOUGHH150RHEflOWNEMPLOYEES,PROVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDE00q m �Q .OFFEREOWRSALEIF�W�ER,THEBUILDINGORIMPROVEMENTISSOLOWITHINONEVEAROfCOMPLE- _ Z 71IXd,T11E OWNER�BUILDER WIIL HqYF.THE BURDEN OF PROYING THPI'ME OR SHE DID NOT BUILD OR � IMPqOVEFORTHEPURPObEOFSALE). . �yJ ❑1,0.5 ONTIEq OF TME PHOPERTY.AM E%Cf.U51VELY CONTRACTING WITH LICLNSF.D CONTMCTOqS - [� TO CONSTRUCT THE PR0.IECT(SEC.701C,BUSINESS AND PROFESSIONS CODE�THF.CONTRACTORS LI- VBIIldfI0f1 __....._..---....._ _ADJ.AREA W CENSEUWOOESNOTAPPLYTOANONMEROFAPflOPERTYWHOHl11L�50RIMPROVESTHERF�N.AND — � WMOCONiRACTSFOR3UCMPROJ[GTSWI7HACONiRACTOR(5)UCENSEDPUflSUANTTOTHECONTRRC- QUANTIN DESCHIPTION FEE Y TORSIJCENSELAW.). 0 ❑I AM EXFMPTUNDER SEC..__ 8.8 P.C.(OR iH15 REASOY U �r _ __--___ � � . � DATE OWNER____.'__ .-.'.'-__ V . � W Q LICENSED CONTRACTORS DECLARATION �yj �; � 1MEFE9YAFFIRMUN�ERPENALTYOFPERIURYTNqTIqMLICENSEOUN�ERPROVISIONSOFCHAVfER � � d. e(COMMENCINGWITHSECTION7o00JOFDIVISION30FTHEBUSINESSANDPROF[SSIONSCODF,ANp z X �A1'IICENSE IS IN NLL FORCF_PND EFFECT. LLI �f�j {..� m � LICENSE CLA S C-' � _LIC.NO. �/`" �d / __ � �. � Q� J VDATE 2 CON7'RACTOR�fi/."�"M`-� _ W ' , � r� WORKERS'COMPENSATIpN DECLARATION cf�� `� -' ��1 /�-GL� ' .- � '� :�:.,,� v �--�Dr/'- /J�- U �f� .�.) . : N IHEHEBYAFFIRMUNOERPENALTYOFPERIURVONEOFTHE(ULLOWINGDECLApATION$r Z 3 �D,/�i �3�1�-6��-� ;�,r- �`J ��� I ¢ , T � 0 _ IH/1VEANDWILLMHINTAINpCER71FICATEOFfANSENTTOSELFdNSUREfORWOHKERS' _ � � COMPENSATION,ASPFlOVIDEDBYSECTION37o90FTNElA90RCOUF:,FORTHEPERFORMANCE U _ � Of THE WORK FOP WHICH iHl&PERMI7IS ISSUED. � ` T a S a�� p .J^ _ ! t� W __I HAVE AND VfiLL MAIMAIN WORKERS'OJMPENSATION INSUHANCG,Ati REQUIflED DY SECTION � , Q 97000F THE LA90R CA�E,FORTHE PERFOPMANCE OF THF.WORK FOR WNICH THIS PE0.MIT IS � 4 ISSUE�.MY W EHS'Cq PENSATION INSURANCE CARRIER AND POLICY NUM9ER ANE: CON,�STRUCTION ..__.__._._ _ !� . ' _._'_--..._ .__. -_.... �� � CARRIER.._ .�T� � ^-� • �e�./�rv REVIEW � _ __....-._. .• ' - __.._-_......._ _____._._. . ....'_'_'_'__ � Z raicrnuMaea n/W"+�'� �, � �7',T 2 '` ��;� ELECTRIC —�} - —.—_...- ---- ---- . Q `�1�at� ��:. � (iF1455[GTIONNE�NOTBEWMPLE7EDOFTHEPERA4fFSFORONEHUNDREDDqLVU'($160) �- p PLUMBING -----..__._..... .._.._... ''". Z I CERTIFY THRT IN THE PERFOfiMANCE OF THE V/ORK FOR WHIGM THIS PERMIT IS ISSl1F.D,� MECHANICAL:� ..._...--_.._ ._.. y �� (�' SNALLNOTEMPLOYANYPEfl50NINANYMANNER50AS708ECOMESUBJLCTTOTHf '�"""""-'-'"'�� ' � WORKEI{S'COMPENSATIONIAWSOFGALIFOHNiA,ANOAGFC[7HATIFISHOULGBECOME •INSPECTIONFEE _.__.,___.___ ._, � ������ ' = SU&IECTTOTHEW9RKER5'COMPF:NSATIONPROVISIONSOFSECTION37000FTHELAB0I7 ] ; COUE, SHAI FOR7HWITI��COMPLYWI THOSEPROVISIONS. �SSUANCE ���� .___ '�J �� � I�QQ -` p� SMIP � Q �ATE: I n�� APPLICANT. _. _�Y1AM-'�-�6 ��1'li'�-- � . Y; _ .._- ._-'...._--'__ W � ENERGY P/C � `. 4"' � WARNING FAILURF.TO SECURE WORK[RS'COMPFNSATION CAV[RAGF IS UNLAWfUL.AND 5FNLL BE "--'-"'-- -"""-" ..:. .._..._.-._...._........___" _. � S U&I E C T A N E M P L O V E R P DC R I MI NALPENALTIESANDCIVII.FINcSUPTOONEHUNDREDTHOUSANU E N E R G Y P E R M I T ___,,_„rI fA�P n r• •t n n n _ ` "; DDLLARS(ita0,000),INADDITIONT07NECOSTOFCOMPENSATION,�AMAGFSASPHOVIO[OFOfiIN -'------- � SECTION9)OBOFTHELABORCO�E,INTEflEST.�NDATTORNEY'SPEES. '� R ���� RETENTION FEE: �,f�y� �q ry�D A a CONSTHUCTIONLENDINGAGENCY PRE-ALTFEE: �`�'dd T 7��7k7�°}.�D�v �ppG,v�ly��'���✓�d+�l.�._, __ �. I HEFEBV AFFIRM UNDER PENAITY OF PFfiJURY TMAT THEIiL I$A CONSTHUC710N I.ENUING AGENCY �^"�.��/,wP.,IA!�0.X?`ti�l F.�,`t.��___J___.___ a- FOR THE PERFONMANCE OF THL WOfiK FOR WHICH THIS PERMIT IS ISSU[D(SEC.3097.CIV C.). ' . Z "____"_ .""._'_'__—_ W - �:�', � LENDEF1'SNAME _— --_... N LENDFR'SAO�RESS ...'_"_.._.._.. ----_-._. _.._._.."___.... � ICERiIFYTMATIHAVEREADTMISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCOHRECT. TOTAL FECS � � . � I AGflEE TO COMPLV WITHALI CITV AND COUNTV ORDINANCES ANU STATE LAWS RF.LATING TO BI1IL�INO CONSTRIICTION,AN�HF.REBV AUTMORI7.E RF.PRF.SF.NTATIVES OF THIS COUNTY TO ENTER UPON THE ZABOYE�MENTIONEO PROPERTV FOR INSPECTION PURPOSES. 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