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HomeMy WebLinkAbout10409 i - =' CTTY OF DIAMOND BAR COMMUN[TY DEVELOPMENT DEPARTMENT :,,,c 21660 E.Copley Drive Suite 190 PRESS (909)860-3L95 Fax(909)861•3117 �'�'� BU[LDiNGPERMITAPPLICATION FfRMLY � JOBSITE APPLICATION PERMIT P/C o ADDRESS -� DATE ���'��� NUMBER/���� # ISSUE �' / �j�ry TYPE OCC $ APN LOT TRACT DATE ��/,��'��-/ / CONST. GROUP p OWNER �� T— " ADDRESS ZONING SETBACKS w FRONT RW I.I Q CITY ZIP TEL. REAR f�) o APPLICANT TEL. SIDEISIDE STREET RW C] � CONTRACTOf3 " � SIDE ❑ p� ADDRES " ':3– PROPOSED USE `� `� � CITY v Z.IP TEL. �-' "' w ARCH/ENG/ 3�� z DESIGNER ��� NO.DWEL. NO. NO. � d ADDRESS UN�TS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � � OWNER-Bt;ILOER DECLARATION SFWADD/REM O p' i HERE6Y AFFIHM UNDER PENIILTY OF PERNIRY TMRT I AM EXEMPT fflOM THE CONTMCTORS LI• G8f8gB/C81�011 W CENSELAWFOHTHEFOLLOWINGREASON(SEC.7031.5BUSINESSM70PROFESSIONSCODE:ANYCRYOR (n U COUNTYWHICHREWIRESAPERMITTOCONSTRUCT,ALTEN.UAOqOVE.DEMOLISH.ORREP4IRANY3iAUC- W patio/Dack W� TIIRE,PRIOR TO ITS ISSUANCE,ALSO flEWIRES TNE APPUCANT FOR SUpI PERMITTO FILE A SIGNED � 9TATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONiMCTORS U- � CENSE LAW(CHAPTER 9(COMMENCINfi WITH SECTqN 7000)OF UIVISION 70F THE BUSINESS AND PRO- LL' POOVSPB FESSIONS CODE)OR hIAT ME OR SME IS EI(EMP7 THEREFpOM AND THE BASIS FOH TME AILEGED EKEMP- 0 710N.ANYVIOlA710NOFbECTIOP17037.58VANVMPLICANTFORAPEfiMI7SUBJECT5THEAPPLICAMTO Z Re-Roaf � ACINLPENALTYOFNOTMORETHANFlYEHUN�PEDDOLUNS(5500�.7: � ❑I,ASOWNEHOFTHEPflOPERTY,ORMYEMPLOVEE6WITHWAGE6ASTHEIRSOLECOMPENSATiON, O COffIfPIBPCiBI Z. K9ll DO TNE WORK,ANO TNE STRUCTURE IS NOT IN7ENOED�i OFFEREU FOR SALE(SEC.70��,BU51- J NESS AND PROFESSIONS CODE:THE CONfRACTORS LICENSE UW DOES NOT APPLY 70 AN OWNEH OF � � PROPEHTYYM09UILUSOHIMPROVEShIEREON.ANDWHODOES3uCHWONKHIMSELFORHERSELFOR = �' THRWaHHI50RHEROWNFMPLOVEES,PROVI0E0TNAT5UCHIMPHOVEMENTSARENOTINTENDEDOR m w OFFEREDFORSALE.If,HOWEVERTMEBUILDINpORIMPROVEMENTISSOtDWIiMINONEYFAROFCOMPLE Z� TION.THE OWNER�BUILOER V�ILL HAVE THE 6UNDEN OF VROVING THAi HE ON SHE DIO NbT 9UILD OR � � IMPRO4EFORTHEPUflPO5EOF5RLE). W C]I,ASOINNEROFTHEPROPERTY,AMEXClU51VELYCON7MCTINGWITHLICENSEDCONTRACiOR5 �. (_'. TO CONSTRIICT THE PRQIECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:T7E GONfMCTORS LI- V2W9110I1 � �� ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEHOFRPROPEN7YWHOBUILOSORIMPROVESIHEREON,MID � �. WHOCANTMCTSFOHSUCHVHQIECTSVM�THACONTRACTOR(5)UCENSE�PURSUANT70THECONTFAG QUANTITY DESCRIPTION FEE �� TORSLICENSELAWJ. J 0 ❑I AM E%EMPT UNOER SEC. 8.6 P.C.PDR TW&flEASON . � �. � LL DATE OKTlER V ' Q4 LICENSED CONTRACTORS DECLARATION W 2 1 HEREBYAFFIRM UNOEF PENALT7 OF PERJURYTHAT I Mi LICENSED UN�ER PROYISION$OF CHAPTER � p,, e(COMMENCINO WITH SECTION 70ao)OF DIVISION 90F THE BUSINESS AND PROFESSIONS COOE,AND Z � x MYUCENSE iS IN FULL FO AND EfFECT. m ` W..: I�i � 5 � LICENSE CLASS UC.NO. /� j U: OATE CONTRACioF�� ^�... r�� ry, d . W,; �� WORKERS'COMPENSATION DECLARATION �� A Q � U � IHEREBVAFFIRMUNDERPENALTVOFPERIURVONEOFTHEPoLLOWINGDECLAMTqNS: �' Z Q �` _I/UVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEfiS' S COMPEN6ATION,AS PROVIDED 8�SECTON]]Oo OF THE LABOR CODE.FORTHE PERf-0HlAANCE U ¢ OF ORK FOR WHICH THIS PERMIT IS IS5UE0. � ' O W INAVEANDWILLMAINTAINWORKEflS'CAMPENSATIONINSUMNCE,ASREQUIREDBYSECTION Q 37o00F THE LABOR CODE,FOR THE PEHFORMANCE OF T E WORK FOR WHICH hIIS PEHA11715 " - ��, �� ' ISSUE0.AIY WORKER P TI INS CE G1 IEHAND POLICYNUMBERARE: CONSTRUCTI� ) � CARRIEP �'� PLAN REVIEW � � POLICVNIIMBER � ELEC'TRIC a l � � �_. p, w. �ssEcrrs�r��rro7eEa'7�a«oofTEaEtaM�s�oNEMx�FDDounFSRtaoloR�ss} PLUMBING ������¢;;,;��9 s��r Z 1 CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WH�CH THIS PERMITIS IS5UED.1 MECHANICAL ~��_ (r} SHALLNOTEMPLDYANYPERSONINpNYM SOASTOBECOME3UBJECTT07HE " ' �� WORNEFS'COMPEN9ATION LAWS OF CALIF RNI,AND AGREE THAT IF�SH4ULDBECOME iNSPECTION FEE . r� = B,IECTTOTNEWORKERS'CAMPENSA P V�SION50FSECT N37000FTHELABOR U p ` , ', E,I SHALL FOflTNWITNCOMPLY WI7 � P ISIONS. ��'� �� �'" " � o �/]-,,- ��'���..... SMIP �;��' ,_'�".; `p DATE: �'"'�� APPLICANT: „ � ENERGY P/C J WAi1NING.FAILUNE TO SECUHE WOHKERS'CDMPENSATION CAYEflAQE IS UNUWFU�,AN LBE LL SUBJECTAN EMPLAYEH TO CIUMINAL VENALTIES AND CIVII FINES UP TO ONE HUNDRED T SANO ENERGY PEflMIT � 'OOLURS(5100,000�,INADDITION TO THE COSTOF COMPENSATION,DAMAOES AS PROVIDED FOR IN QSECTION37o80FTMELABORCOOE.IN7EHES7.ANDATTOqNEY'SFEES. RETENTI�NFEE: a CONS7RUC710N LENDING AGENCY PRE-ALT FEE: � IHEHEBVAFFIRMUNOEN7ENALiVOFPERIURYTHATTHEHEiSACONSTRUCTIONLENDINOAGENCY �� FOR THE PEflFORMANCE OF THE WOF1K FOR WHICH THI6 PERMIT IS ISSUED(SEC.3ou�,CIV,C.). /N . � S � W � IENDER'S NM�E H IENDER'SRD�RE55 : � TOTAL FEES C��' W ICERTIFVTHATIHAVEREADTMISMPLICATIONANDSTATETHATTHEABOVEINFORMA710NISCORRECT. �� � d IAGREETOCAMPLYWITHALLCITYANDfAl1NTYORDINANCESANDSTATELAVY3flELATINGTOBUILDING CONST ,AND HEREBYAUTMONIZE REPHESENTATIVES OF TMIS COUN7V TO ENTER UPON TNE ry/ Z ABOV-MENT ED PROPERTY FOR INSPEC710N PURPPSES. 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