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HomeMy WebLinkAbout15611 „ , „�,, _�,� CITY OF DIAMOND BAR � � t � � � DEPARTMEN'f OF COMMUNITY&DEVELOPMENT SERVICES r b���t1 I _W . 21660 E.Copley Drive 5uitc 190 � (909)860-3195 Fax(909)861-3117 PRE$$ ";9N°�� BUILDING PERMIT APPLICATION _ .,. . FIRMLY _ _ _ _ ,� .:. _.. � JOBSITE APPLICATION G�/ PERMIT ��j� P!C o ADDRESS ��'�� �\��'�''� ��� �` DATE � l NUMBER �`/ � # $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP ¢ OWNE�t� �G�7'fi�.�.i13�°3� O ” ADDR€SS z ZONING SETBACKS � cirr ���%� ZIP4lt�6-C�� TEL. REORT RW 0 APPUCANT TEL. SIDE/SIDE STREEf RW ❑ � CONTRACTOR SIDE p � ADDRESS � CITY ZIP TEL. PROPOSED USE 0 ARCWENG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFWADD/REM � I HEflEBV AFFIIUI UN�ER PENALTY OF PERJURY iHAT 1 AM EXEMPT fROM THE CONTRAC70flS ll- � (`,arage/Carport W CENSELAWFOIiTHEFOILOWINOREASON(SEC.7a3t.5BUSINESSANpPROFE5SpN5CODE;ANVCI7VOR V COl1NiVMMICNNEIX11qESAPERMITTOCONSTRUCT,ALiEH,IMPROVE.DEMOLISH,ORREPAIRANYSTRUC- `W pyti0/DBCk WTURE,PRIOR TO RS ISSUANCE,ALSO REOUIRES 7HE APPUCANT FOR SUCH PERMI7 70 FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO TME PRpVI51aJ5 OF THE WNTRAC70RS LI� � CENSEUW(CHAPTERB(COMMENC�NdWITHSECilON7a10)OFDIVISION30FTHEBUSINESSANDPRO- � PODUSP& FESSIONS CODE)OR THAT HE OR SHE IS E7(EMPT7HEREFROM ANO THE BASIS FOR TNE ALLEGEO EXEMP� TION.ANVVIOLATIONOFSECTION7031.5BYANYAPPLICAN7FORAPERMITSU&lECTSTHEAPPLICANTTO Z RB-R001 � A CMLPEN1ILTY OF NOT MORE THAN FIVE HUNDRED DOLLARS�f50D)J: � OI,A30VMEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, O Commercial - WILL D�7HE WOAK,AND hIE STRUC7URE IS NOT INTENOE�OR OFFEftE�i0R SALE(SEC.7aa.BU51� J NE33 AND VflOFES310NS COOE:THE CANTRACTORS�ICENSE LAW DOES NOT APPLY TO AN OWNER OF � PpOPERTYNIHO6UIlDSORIM7ROVESTHEREON.ANDWHO00E55UCHWORKHIMSELFORHERSELFOR = � THROU(3HHI301iHEROWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEMENTSARENOTINTENOEDOR � W OFFEpEOFOHSILLE.IF,HOWEVERINEBUIl01NGORMPROVEMENTIS50LDWITHINONEVEAROFGOMPLE � TION,THE OWNER-BUILDEH WILL HAVE TNE BURDEN OF PROVING THAT HE bR SHE DI�NOT 9UIID Op = IMPROVE FOp THE PURPOSE OF SALE�. w ❑I,ASOWNEROFTHEPROPERN,AMEXCLU5IVELYCANTRACTINOWITNLICENSEOCOMRACTORS � TO CONSTRUCT THE PROJECT�SFC.7044.BUSINE55 ANO PROFESSIONS CODE:THE COMTqACTORS LI� Vall18fi0f1 , ADJ.AREA W CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPROVESTHERE�N.AND � WFqCONTRACTSFORSUCMPROJECTSWITHACONTflACTOR(S�LICENSEDPURSUAMTOTHECONTRAG QUANTIIY DESCRIPTION FEE � TOIiS LICENSE LAW.}. � p IAM EXEMPT UNOER SEC. 8.&P.C.FOR THIS PEASON Q � __ U a � DATE D�NEA_ U � LICENSED CONTRACTORS DECLARATION -� � W I NEREBYAFFIRM UNDEF PENALTY OF PEPJURV THAT I AA1 LICENSE�UNDER PROVISIONS OF CHAPTER � D(COMMENqNOWITNSECTKKJ7000)OFDIVISION30FTHEBUSiNESSAN�PROFE5510N5CODE,AN� Z �'� �L�'�'� X MYUCENSE IS IN NLL FOpCE AHD EFFECL a m 0 LICENSECLASS��3� LIC.N�. "~���G� � V �ATE �.�" / - CONTRf.CTOR_ ��"-S.- a W � WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNDERPENALTYOFPEPJURYONEOFTHEFOLLOWINGOEqARATIONS: U � Z Q O IHAVEANDWILLMAINTAINACERTIFlCATEOFCON&ENYTOSELF-INSUREFOHWORKERS' _ � CdAPENSATION.ASPRONOEf1BVSECTION37000FTHELABORCODE.FONTHEPERFORMANCE V OF THE WORK FOF WMICM THIS PERMIT IS ISSUED. � C _I HpVE AND WILL MNNTAIN WORKERS'CAMPENSATION INSUIIANCE,AS REQUIRED BY SECTION QQ 37W OF TME LABOR COOE,FOR THE PERFOPMMCE OF THE WORK FOi7 WHICH THIS PERMIT IS ISSUED.MYWOPKERS'�ENSA�yTI,O�NINSl1nRANCECMRIERAN�POLICYNUMBERARE CONSTRUCTION � CARFIEH ` •""`�{�'y`��y�����'��7��,5 pLANFEViEW � POLICVNUMBEF ��`�./��✓ ELECTRIC Q 0 fr�ussEcrnHNE�r�oreEeau�.ErEooFn��wr�S�rnoNEw�wa[�ca_i,uis�s�m)oa�ss} PLUMBING __ — Z I CEP,TIFY THAT IN THE PERFORMANCE OF THE 1YORK FOR WNICH THIS GERMIT IS ISSUED.I MECHANICAL (S SHPLINOTEAAP40YANVPERSOMINANYMANNEFSOp5TO8E�OMESU&IECTTOTHE � WORKERS'COMPENSAiIONlAW50FCA1.IFOflNIR,ANDAGREETHATIFISHOULDBECOIAE �NSPECTIONFEE SUBJECT TO THE N�DFlKERS'COMPENSATION P CTION 3�o00F THE LABOR �p ry, � CODE,I SHALL FORTHWITH CadPLY WITH TH .E PROV:SIONS. �SSUANCE C�L M ��-� 0 SMIP �+ ' p DA7E��'�-Lti� qPPLICANT.__' . . l�,�* .. �.. W . l B-:� o,:fln...x�..�*. , -� WMNING�FAIWRETOSECUREWORKERS'COMPENSATIONCOYERAGEISUNUWFUL,ANDSNALLBE ENERGYPJC-�} �t y � � SU&IECTAIVEMPLOYERTOCqIMNAL?ENALTIESANOCNILFINESUPTOONEHUNDREDTHOUSANO ENERGYPERMII��""'' �'i��?t���� , ti . DOLL4RS(5700,000).�N AOOITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN � SEf.TION 3708 OF THE LABOR CODE,INIEREST,AND ATTORNENS fEES. ' RETENTION FEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBV AFFIqM UNDER PENALTY OF PERJURY THATTHERE IS A CONSTRUCTION LEN�ING AGENCY � FOR THE PERF-0RMANCE OF THE WdRK FOR WHICN THIS PERMIT IS ISSUED(SEC.3oe�,CIV.CJ. Z W � LENOERSNAME F- LENDER'SAODRESS /�/y� � ICERTIFYTHATIHAVEREADTNISAPPLICATIOnIANOSTATEiHATTHEABOVEINFORMATIONISCORFiECT. TOTAL FEES -/ � I AGREE TO CAMPLY W1TH ALl CITV AN�COUNN OFDINANGESAND S1ATE L4WS RELATING TO BLIILDING ! � CONSTRUCTION.AND HEREBV AUTNORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER I/PON THE L Z ABOYE-MENTIONED VflOPER INSPECTION PURPOSES. COMMENTS � =-����.��: QPERMITTEE NAM (PRIN'n -� �, �2.� � SIGNATURE OF PERMITTEE OATE = RECPT.N0. PAID BY VALIDATON ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,G LD NROD—File Copy.GREEN—ApplicanYs Copy ����� �"`.�� ��:�������°�� ��a� .,�, ._ � � ������ ���� :�-.� �, ���-� ���a �`� �.. � � ° ;� �� ' a � . � ��, ����.��� � �,� . �� � � ��' a,� �� ��� �� � � � # '� `�����: � �_��' .'�". .��.���'" ��� �` .. �,.: .,�'..��. ,.: ��� � ���,�� ��.. �.:'_� . ,.: ..... .� ,.� �a4 ��� �s�� .... ar�'�.- s CG—t I�, T, , � , . , r ' � �'3 `�r`��t �i . 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