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HomeMy WebLinkAbout10410 (5) � " CTfY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT ;,,� 21660E.Copley Drive Suite 190 PRESS � (909)860-3195 Fax(909)861-3117 I .""' BUILDING PERMIT APPLICATION FIRM LY I < DDR1 SS p� .,� APPLICATION /� r � PERMIT ��l�/s�� P/C o DATE ( �r�J��.�NUMBER # I c� ISSUE TYpE OCC APN T TRACT DATE����'�'�� CONST. GROUP I p OWNER � o ADDRESS ZONING SETBACKS � z CITY � ZIP TEL. ��r FRONT RW ❑ o APPUCANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTO q �L•'� SIDE ❑ � ADDRESS � �- � CI7Y y ZIP���TEL.�����yy._ PROPOSED USE �..- : C.E J w ARCWENG/ �� - � ' Z DESIGNER � ' ' W NO.DWEL. NO. NO. a ADDRES3 UNITS STORIES __�BEDROOMS � CITY ZIP TEL. f u DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION I � OWNER-BI:ILDER DECLARATION SFR/ADD/REM O p, 1 HEREBV AFFIPM UNDER PENALT'OF PERJUflY THAT I AM EXEMPT FROM TNE CONTMCTORS LI� G8f8 B/C8 IL W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSANOPROFESSIONSCODE:ANYCITVOq (n 9 � U. COUNTYN7iICHREOUIRE3AVERMITTOCONSTflUCT,ALTEH,IMPROVE.DEMOLI6H2ORREPAIRMlYSTRUC• W P8Ii0/DBtI( ' �� 7URE,PPIOP TO ITS ISSUANCE,ALSO REW IRES THE AOPLICANi FOR SUCH PE WAR TO FILE A SI6NE0 w S7ATEMENi THpY HE OR BHE IS LICENSEO PUR5UANT TO THE PqOVI510NS OF THE COPITMCTOflS LI� � CENSE LAW�CHMTER B(COMMfiNCIN6 WITH SECTION 7aW)OF DIVISION 8 OF THE BUSINESSAND Pp4 � PaoUSpe O FESSIONSCOUE)ORTIiATHEOH5HE13E%EMPTTMEREFROMANUTNEBASISFORTHEALLEQEOE%RIP• � V TIW�,pryYYIOLATIONOFSECT10N7031.66YANVAPPLICANTFORqPEFMITSU&IECTSTHEAPPLICIWTTO Z Re-Raoi � A CINL PENALTV OF NOT MORE THAN FIVE HUNOREO OOLLARS(5500).�: � �� ❑I,ASOWNEflOFTHEPROPERTV,ORMYEMPLAVEE3WITHWAGE5A5TMEIflSOLECOMPENSATION, ' 0 COfI1RIBfCIdi WILLDO THE WONK,M7�THE STNUC7URE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70e�,BU51� J � N NESS ANO PqOFE5510N5 CODE:THE CONTRACTORS LICEN&E LAW DOES NOT AVPLY 70 AN OWNEft OF = � PROPERTYN4WBUILDSORIMPROVESTHEREON,ANONMODOESSUCNWOpKHIM6ELFORHERSELFOR Q� TNHOUGH MIS OqHEROWN EMPLOYEES,PROYIOE�TNAT SUCX IMPpOVEMENTSARE NOT MTENDEOOR m W pFFEREDFORSN.EiFHOWEVERTHEBUil01NGORIMPROVEMENTISSOIDWITHINONEYEAROFCOMRE� �� TION,THE OWNEN-BUILOER WILL HAVE iNE BUROEN OF PROVING THAT HE OR SHE DID NOT Bl11LD OR �' IMPqOVEFORTHEPURPO5EOF9ALE). ' �y,� ❑I,ASOWNEROFTHEPROpERTv,AMEXClU51VELVCONTRACTINGWI7HUCENSEDCON7PACTORS . > Q� TO CONSiqUCT THE PRQIEGT(SEC.70K,BUSINESS PNO PROFESSIONS CODE:THE COPf(MCTORS LI� V8N811W1 ADJ.AREA W . CENSELAWDOESNOTAPPLVTOANOWNEROFAPqOPERTYWHOBUILDSORIMPROVESiHENEON.ANU '� �� WHOCONTRAC75WF5l1CHPflOJECTSWITHACONTpACiOR(�UCENSEDPURSUANTTOTHECON�MG QUANTITY DESCRIPTION FEE TOHS LICENSE IAW.). Y' J On I MI E7(EMPTUNDER SEL. 8.6 P.C.FOR THIS REASIXV . a �; U �: ' N oare OWNEH V O W a LICENSED CONTRACTOFS DECLARATION W OC �HEREBV AFFIRAI UNDEq PENALTV OF PE{UUPY THAT 1 AM LICENSEO UNDER OqpVISIONS OFCHAP7ER � d-' 9(COMMENCINGWITNSECTION7000)OFDIVISION30FTHE8USINESSANDPROFESSqNSCODE,MID Z 'X'� MY UCENSE IS IN FULL FO ANO EFFECT. m Q� � ��. LICENSECLASS �LIC.NO. � V•- DATE �' � CONiRACTOH a W. ' �1 �` WORKERS'COMPENSATIONDECLARATION C,� ' � t �i �:. I NEflE9YAFFIflM lJNOER PENALTY OF PERIURY ONE OF THE iOLLOWING DECLAMTqNS: Z �� ��'� _INAVEANDWILIMAINTAINRCERfIGICATEOFCANSENiTOSELF-INSUREFORNqRKERS' _ ' �; �NSATION,AS PqOVIOED BV SECTION 370DOF THE LABOR CODE,FOFl THE PERFONMANCE �U 7ME WOflK FOfl NMICH iH15 PERMIT IS ISSUED. � W I HAVEAND WILLMAINTAIN WORNEHS'COMPENSATION IN5URANCE,AS REOUIREO Bv SECTION �/ �, Q 37000F THE LABOR COOE,FOR THE PERFOqMANGE OF 7HE WOF Wfl WHICX THIS PERMIi IS ����, .9 �� ISSUED.MYYlORNERS'COMPENSA710N INSURANC RRIER ICY NUMBEfi ME: CONSTRUCTI s„ J. ,,�i"":..i1. j CAflRIER_ � PLAN REVIEW .�..v,, i;�� :>•: r � ` ,: �;g ^;,,.�, �:q,.. . � I Z POLICYNUMBER �� j '� ELECTRIC `�.. �' s,:.:+':'"..�:': t . Q Y �� (IH6SEC11aNNE�NOTBEaoMREi�aFnEDERMf6fdRQVEtNPDRE�D01-tARs(Stro1�tESS} PLUMBING ' W _ Z . I CERTIFV THAT INTHE PERFOMIhYCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSI)ED,1 MECHANICAL ��'���� �' C�7� SHALLNOiEA/PLOYANYPERSONINANYMANNER50qSTOBEOOMESU6IECTTOTHE a.5pex� k '�, " " (/), WOHKERS'COMPENSFTION LAWS OF GAL�FOHNIA,AND AGFEE TFIAT IF I SHOULA BECOME INSPECTION FEE � SU&IECT TO TNE WORKERS'CAMPENSAT iPROVI510NS OF S CTKKJ 9700 OF THE UBOR "'�'�^+. P ," -� /' � CAOE,ISNALLFOHTHWITHCOMPLYWI SE VI51 5. �SSUANC �� • ��°/�' O DATE: �� f APPLICAN, � / SMIP r „i � �p " � • �J ENERGY P/C � 'WARNINO:FAILURETOSECUREWDIiKERS'COMPENSATIONCOVERA6EISUNIAWFUL, SHAILBE LL SUBJECTANEMPLOVER70CRIMINALPENALTIESANDCIVILFINESUPTOONEHUNOHED WSAIJD ENERGYPEflMIT - .DOLLARS�S100.000),INADDITIONTOiHECOSTOFCOM7EN5AT10N.DAMAGESASPflOVIOEOFORIN ¢� SECTpN37080FTHELABORCODE,INTEREST,N�IDATTORNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBY AFFIRM UNDER PENALTY OF PEFiIUfl�THAi THEHE I5�CONSTqUCTION IENDMO AGENCY Z FOR THE DERFORlMNCE OF TNE WORK WR WHICH THI5 PENAIITIS ISSl1ED(SEC.30B7,CIV.C.). �i R� ^ / W J` d•t 6r ' � LENOEWSNAME �' �. �5 LENOER'SADDRES5 I� w ICERTIFY7XA71HAYEREAOTHISAPPLICATIDNMIDS7A7ETHATiNEA80VEINFORMATKKJI3CARRECT. TOTALFEES �'�' ��I . � IAQPEETOCOMPLVWITiiALICINANDCOUNTYOR0INANCESANDSTATEtAWSRELATINGTOBUILDING � GONSTRUCTION.Af�HFAEBVAUiHORIZEREPHESENiATIVE50FTHISCAUN7YtOENTERUPoNTHE n � .��Jy/�•� I'.� Z �BOVE�MENTIONEDPROPEIiNFORINSPECTIONPURPOSES. COMMENTS �'C-I�'Y.S ���.JH � 'J = r'�--�:a r� QaMirr tv i , _ �• �....cn,.....-. 'y„'_'..,- ,� �;r-`�� y SI6NA FPERMITTEEO D�TE --T— RECPT.NO. 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