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HomeMy WebLinkAbout11004 � � �`�'��I --- CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT ' :o� . 21G60E.Copley DriveSuitc 19b PRESS (909)860-3195 Fax(909)861-31]7 '°"'�� BUILDINGPERMTI'APPLICATION FIRMLY o DDRESS IY��� �1f�ff%Er•..Z� C-�Y�✓�� Ui3 DATEICATION �Z.- � -'� Nl1MBER� ��/� #/C $ APN LOT TRACT �SSUE TYPE OCC DATE__, CONST. GROUP p OWNER _L_�L � � � p ADDRESS � � C - `' 'I��� ZONING SETBACKS Z CITY I/ Q 21P�TEL. '� '_��;t=a`_ 7 FRONT RW ❑ o APPLICANT TEL.�`�'�'�l�- REAR _ _ f I_ z SIDE/SIDE STREET RW �l a CONTRACTOR ` � �'�{„�-f SIDE _ ❑ � ADDRESS I p C�.�,� „ r� ��P����/��[ PROPOSED USE_ o ARCH/ENG/ iz DESIGPJER NO.DWEL. NO. NO. a ADDRESS - UNITS STORIES BEDROOMS � CITY ZIP TEL. — � -- �n DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATIDN p�. OWNER-BCILDER DECLARATION SFRIADD/REM O � I HEREBY AFFIPM UNDER PENALTY OF PER,IURV THAT 1 AM EXEMPT FROM THE CONTRACTOHS LI- ' G8f7]g/Cdf�lOf[ W. CENSELAWFOHTHEFOLLOWINGflERSON(SEG.7031.SBUSINESSANDPROFESSIONSCOOE:ANYGITYOR : (f� ' U CWNTYWHICHREOUIRESAPERMITTOCO45YFlUCT,ALTER,IMPflOVE,DEMOLISH,ORREPAIRANVSTPUC- ' � patio/Deck w�. NRE,PRIOR TD 175 ISSUANCE.AL50 REOUIflES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNEO ' STATEMENT THAT HE OR SHE IS LICENSEU PURSUANT TO iHE PPOVISIONS OF THE CONTRACTOPS LI- � CENSE LAW(GHAPTER 9(COMMENCING WITH SECTIDN 7000)OF DIVISION 30F THE BUSMESSAND PRO. V' POOUSpO � fE6SIONSCODE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXfMP� (� V TION.ANYVIOLFTIDNOFSEGilON7031.5BYANYAPPLIGANTFOFAPERMITSU&IECTSTHEAPPIICAN770 ' Z Re-Roof A GVIL PENALT'OF NOT MORE THAN FIVE HUNDflED DOLURS(f50o).): 0 LII,ASOWNEROFTHEPROPERTY.ORMYEMPLOYEESWITIiWFGE5A5THEIFSOLE.CAMPENSATION. ; � COTrtIBfC13� � Z WILL DO THE WOflK,AND THE STRUCTURE IS NOT INTLNDE�OR OFFERED FOfl SAL[(SEC.7044,BUSI- J NESSAN�PFOFESSIONS CODE:THE CON7RACTORS LICENSE LAW OOfS NOTAPPLY TO AN OWNEfl OF � PR07ERTYWHOBUILOSOPIMPROVESTHEREON,MIOWHODDESSUCHWORKHIMSELFORHEFSEIFOR � 2 THROUGHHISONHEROWNEMPLOYEES,PRDVI�EDTNpTSUCHIMPROV[MENiSAFENOTINTENDE00R m I Q OFFERE�FORSALE.IFHOWEVERTHEDUILDINGORIMPftOVEMENTI550LOWITHINONEYEAROFCOMPLE- Z TION.THE OWNER-BIIILDEN WILL HAVE THE BUR�EN OF PROVING THAT HE OR SNE DID NOT 6UIL�OR � IMPflOVE FOR THE PUflPOSECF SALE). �y„� fJ1.A5OWNEFOFTHEPROPERTY.AMEXCLU5IVELVCONTRACTINGWITHLICENSEDCONTflACTOFS � TO CqNSTRUCT THE PROJECT(SEC.704I,&1SME55 AND PROFESSIONS CODF�.THE CONTflACTORb LI- Vellldfi0fl __ ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPFRTYWH06UILOSORIMPROVESTHEHEON,AND ��. � WHOCONTRACTSFORSUCHPRf]I[CTSWITHACONTRACTOq(S)LICEHSEDPURSUANTTOTHECONTRAC- DUA I DESCRIPTION FEE Y TORSLICENSELAW.�. � ❑1 AA/EXEIAPT 11N�EN SEC. 9.8 P.C.FOfl THIS REASON Q �� � _'""'_'_"— . , . (� , �'. .------ -'----- --- — �� � � .. LL' OATE..__ '_'__'OWNER __'_'_ __' U Z w �� LICENSED CONTRACTORS DECLARATION ' W � IHENEBYAFFIRMUN�ERPENALTYOFVERJURYTHAT!aALICENS£�l1N�ERPROVI510NSOFCHRPT'eN �. �� 2 d 9(COMMENCING WITN SECTION 7000)OF DIVISION 3 0F TNE BUSINESS ANp PROFESSI045 CODE,!�D Z `X A7V UC[NSE IS IN FULL FORC[AND EfFECT. m ^ a O � �� . �. LIGENSE CLA55.___ ��G.N0.__.. � .� +_ � � V DATE Z.+� CONTRACTOR. . _ z:.. d �.'. W �� WORKERS'COMPENSATION DECLARATION ��� Z 1 HENEBV AFFIqRI UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECLARAT Z� _I HAVE AND WILL MAINTAIN A CEPTIFICATF.Of CANSFNT TO SELF-INSURE fOR WOqKERS' _ -�� CAMPENSAiION,AS PflOVIDEf7 BY SCC710N 37000F TNE LABOR CO�E,FOR TME PERFOFlMMICE U f a O E WOflK FOR WHICH THIS PEHM1713ISSUED. � i � ; w I HAVE AND WILLlAAIfJTAIN WORKERS'IXMAPF.NSATION INSURA�CE.AS REOUIRED BY SECTIIXJ � Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCe OF THE WORK FOR WHICH THIS PEFMR IS . € ISSUED.MV WOR�NEn(iS'�CO,,MVENSAfION INSUqANC�E CAfiRI�EN AN�VOUCY NUFIBER ARE: CONSTRUCTION _,____ _ j CAHFIER�SL _3_:Gl'"�G"'�� ----- PLAN REVIEW _..----_ — ZPOLICYNUMBER�;��/_T����1�, ELECTRIC _ __ Q � (ililSSEcipNNE�IJoieEoc4FtEfEDOrTi�EPEFiAvrISWRaNeHlx�ltF.�DOLLAfiS(Staa)ORLE551. PLUMBING _ __ � � � � ' I CERTIFY THAT IN THE PERFORMANC[OF THE WOHK FOR WHICH THIS PERMIT IS ISSUEU,I MECHANICAL _ , (� SH�1LL NOT EMPLOY ANY VERSON IN ANY MMiNEfl SOAS TO BECOUE S110.1CCT TO THE r � WORNERS'LOMPENSATION IAWS OF CAI.IFOPNIA,AND AGREE TMAT IF I SHOUlO PECOME INSPECTION FEE __._ _, I \ •� -.: r SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOF IONno00FTHElABOR �. y,,,. 3 � . CQDE.ISHALL ORTMW(TMCAMPLYWITMTH ov�swNs. ISSUANCE eF��x+ ":,�;����_ __ � ��'j���APPUCANL _�_. SMIP '�;j_ p �ATE. -_._ . `---' J ;WARNING`.FAILURETOSECUREYlORKERS'COMPENSATIONCOVEHAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C _____ ___ _,_, ___ LL SUaIECTANEMPLOYERTOCRIMINALPENALTIESAN�GIVILFlNESUPTOONEHUNOREDTHOUSAND ENERGYPERMN -DOLUflB(5100,000),IN A�DITON TO THE COSi OF COMPENSATION.DAMAGfS AS PROVIDED FOR IN �p. ---- — � 'SECTION3708 OF THE LA80R CODE,INTEREST,AND ATTORNEY'S FEES. C..���— RETENTION FE�� __ �W., CONSTRUCTION LENDING AGENCY ___ __,_ o PRE-ALT FEE: � IHEREBYAFFIiiMUNDEflPENALiYOFPERJURVTHATTHEREISAfANSTRUCTIDNLENDW6AQENCY a- FOR THE PERFORAIANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1E�(SEC.3097,CIV.C.�. Z w —--- — — � LENUEH'S NAAIE,.,, _____ ______ ._ _ _ F= LENDEA'SADDRESS ¢ I CERTIFY TNAT I HAVE READ THISMPUCATION AND STATE THAT THE ABOVE INFOPIAATION IS fAfiRECT. TO 1 AL FEES ��'� �� w IAGHEETOCOMPLVWITMALLqTYANDGOUNiYORDINANCE3AN�SiATEUN�SRELATIN6TOBUILDING � CONSTRUCTION,ANDHEREBVAUTHORRERGPRESENTATIVESOFTHISCWN7VTOENTERUDONTHE � A60VE�MENTIONEO PROP[RTY F fl INSPEGTI N PURPOSE5. z COMMENTS _ `"f"�/� �C°t�. _ __�QL.. �L G� �C.3 m PERMITfE ! 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