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HomeMy WebLinkAbout11990 (6) _1F� _ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fa�(909)861-3117 PRE$$ �����'�� BUILDING PERMIT APPLICATION FIRMLY a ADDRIESS 2 U �4`I f!/�'�i���� DATE'CATION�r��I�� NUMB R a #/C v � ISSUE NPE OCC � APN LOT TRACT DATE CONST. GROUP � OWNER O p ADDRESS_ S�✓h� ZONING SETBACKS z CITY ('- ZIP TEL REART RW ❑❑ g APPLICANT _ �.�f-� TEL. SIDE/SIQE STREET RW ❑ � � CONTRACTOR G � �"vc SIDE ❑ ADDRESS o CITY ZIP ji773 TEL. `fa95'�J� PROPOSED USE � ��r � t� � � � DESIGNER '�1.-�I-��' ? ���E. $ � ADDRESS NO.DWEL. �NO. � NO. _ UNITS STORIES ` BEDROOMS � � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �-__ OWNER-BUILOER DECLARATION SFR/ADD/REM O ' �: 1 HEREBY AFFlflM UN�ER PENAITY OF PERIURY hIAT i AM E%EMPT FqOM THE CONTRACTORS LI- - G8/flQ8/CBfPOfI � -y.1- CENSEIAWFORTHEFOILOWMGREASON(SEC.1031.561151NE5SANDPROFE5510N5WDE:ANYCITYOR _(n _ � �J- COUNiYV.MiCHPEWIRESAPERMITTOCONSTRUCT,PITER,�M7ROVE,OEMOLISH,OqREWIRANYSTiiUG --•W- IURE,-PPIOR TOITS IS3UANCE,-AL90 RE�UIRES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIONED W� P8i10/OBCk : STATEMENT TF7AT HE OR SME IS LICENSE�PURSUANT TO TXE PROVISIONS OF TNE CONTRACTORS LI- �- CENSE L4W(CHAPTER 9(CONMENqNG N7TH SECTION�000)OF DIVISION 3 OG THE BUSINESS ANO PRO- `- �' POOVSj10 ��-: FESSIOtJSCO�E)ORTHATHEOHSHEISEXEMPTh1EflEFROMANDTHEBASISFORTHEAIIEGEDEXEMP- V- TION.ANYVKK.ATIONOFSECTION7031.5BYANYAPPLICANTFDRAPERMIiSU&IECTSTHEAPPLICANiTO g-F7ppf `Q - - ACINLPENAIiYOFNO7MORETHANFIVEHUNDREDDOLLARS(S5o�)J: �; ❑I,ASO4MEROFiHEPftOPERTY,OFlMVEMPLOYEE6WIiHWAGESASTHEIflSOLECOMPENSAT�ON, ❑ CO(I1f118fCIdI ' .Z.; WILL 00 T11E 1NORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR ShLE(SEC.70aa,BU51- . J � - NESS AN�PROPESSIONS CODE:hIE CONTRACTOFS LICENSE UW OOES NOT APPLY 70 qN OWNER OF �' PROPEHTYYM1iOBUIIDSORIMPROVES7HEREON,ANDNMO00ESSl1CHWORKHIM6ElFORHEHSELFOfi � - --�; THROUGHHISORHEflOWNEMPLOYEES,PROVIDE�THATSUCHIMPROYEMENTSARENOTINTENDE�OR - m - - F -W_ OFFEHEDFORSALEIFHOWEVEF�iNEBUILDINGORIMPROVEMEMi550LDWITHiNONEYEAROFCOMPLE- - - � -�= TION.THE OWNER-BUILDEfl WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE�I�NOT BUItD OR . -Z� IMPROVE FOR 7ME PURPOSE OF SALE). - � - .W- ❑I.ASOHRiEROFTHEPHOPERf1;AMEXq.USIVELYCOMRACTINOWITHLICENSEDCOMRACTORS -�: 7000NSTRUCTTHEPROJECT(SEC.7n14,Bt1SWESSANDPPOFESSIONSCODE:THEWNTMCTORSLI- VeIUflS10� ADJ.AREA --W-- CBISELAWDOESNOTAPPLYTOANOWNEflOFAPROPEflTYWH00UIlD50RIMPROVESTHEREON.ANO _�- NTIOCONTMCTSWRSUCNPROJECTSWIiHACONTRACTOR(S)UCENSEDPURSUANTTOTHECONTfiAP � QUANTITY DESCRIPTION FEE - TORS LICENSE IAW.�. - Y: �¢- ❑IAM EXEMPT UN�ER SEC. B.&P.C.fORTH15 REASON .- __ U - �: -�- � - - . . . . -LL"--: DATE OWNER -� � - - W '_o-��. LICENSED CONTRACTORS DSCLARATION � - W .�-- IHEflEBYAFFlRAIUN�ERVENALTYOFPEFUURViHATiAMUCENSEDUNDERPROVISION50FCHAPTER � � =�> 9(COMMENCINGWITHSECTfON7oao)OFDIVISIOYSOFiHEBU51NE55FNDPROFES510NSCADE.AND . Z - A1Y LICEN9E I5 IIJ FULL FORCE AND EFFEC7. - _ m �� /� � Q / r ` � -0'. UCENSECLA55 C " �_�LIC.NO. (2 ' - -� `_v= �are -7^2_�-� J CONTRACTOR a W �1(�' '� . . . WOflKER$'GOMPENSATIONDECLARATION _ :yY`_t'� � _ _ _ _ _ _ _ _ _ ¢ 'N-� IHEHEBYA�IRMUNOERPENALTYOFPEFUURYOYEOfTHEPoLLOWINGDECLARATION$: � �;: � -,0t� IHAVEANDWILIMRIYTAINACERTIFlCATEOFCONSENT70SElF�WSUREFOHWORKEflS' y ='�� - COMPENSATION.ASPROVIDEDBVSECTION3'laoOFTliELA80flCWE,FORTHEPEfiFOflMANC'c W OF 7HE WOflK FOR WMiqf h115 PEflMIT IS ISSUED. � �' � -.W' i HAVEAND WILLMAiMNN WOflKERS'Ca.APENSATION INSUMNCE,A5 RE�UIRED 8Y SECTION �:¢_ 37oaOP7HELA80RCODEFORTHEPERFORMANCEOFTHEWORKFORWHICH7HI5PEnM1715 --0`� ISSUED.MY WORKERS'COMPENSATION INSUHANCE CARRIER AND POLICV NUMBEHARE: CONSTRUCTION �� --�--j-� cnaaiea - PLAN REVIEW `--0Z; aoucvNUMses � ELECTRIC zQ��:_, -(nass[crariNE�rrorsEcornr�erIDOF'rr�aEanar�sroaoNE�Eooau,asR�ooloa�ss} PLUMBING 'W I CERTIFV THAT IN TNE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL =Z y('f1e SHALLNOTEMPLOYANYPERSONINANVMANNERSOASTOBECOMESU&IECTTOTHE `__�; -WORIfERS'COMPENSATIONLAWSOFCALIFORNIqANDAGflEETMATIFISHOUL�BECOME INSPECTIONFEE - �'�" -SUBJECTTOTHEWORKERS'COlAPENSATIOYPROVISIONSOFSECTION37000FTHELAB�R CODE,I SHALL FORTHWITN COMPLY W ITH TH/O�SE Pft/OVIS7IONS. �SSUANCE / .O. oa�: �2."�' � fC�( �-__ � -SMIP p; naruc�wr. �,•-.«_ -W�- ENERGY P/C -J' WpRNING�FAILUFE TO SEWRE WORKERS'COMPENSATION COVEHAGE IS l7NLAWFUL,AND SHALI BE - --��� SIl&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFlNESUPTOONEHUNDflEDTHOUSAND � ENERGYPERMIT -- DOLURS(E1 W.000).IN ADDITION TO THE COSTOF COMPENSATION,DAMAGES AS PFOYIDED FOR IN :-��.�_: SECTION9708OFTHELABORCODE,INTEREST,ANDATTOFINEI"SFEES. RETENTIONFEE: - :`d' CONS7RUCTION LENDING AGENCY PRE-ALT FEE: _;��_���.:; IHEREBVAFFIRMUNDERPENAL7YOFPERJURYTHATTHEREISACQYSTftUCTIONLENDINGAGENCV FOR THE PERFORMANCE OF THE WORK PoR WHICH THIS PEHMIT IS ISSl1E0(SEC.3097,CIV.C.�. Z W. -'-�', LEN�ER'SNAME - -F-- LENOER'S.'�DDFE55 �.� //�� //i�� �- 1 CERTIhI'THAT I HAVE RFAf)THIS APPLICATION ANU STATETHATTHE A80VE INFOflMATION IS CORRECT. TOTAL FEES - �-�V'.f 4P 1�;: I AGREE 70 CAMPLY WITH aLl CITYAND COUNTY ORD�NANCES AND STATE LAWS RELATING TO BUILDWG � . � CONSTRUCTION,ANDH[REBYAl1TFiOflREREPRESENTATIVESOFTHISCOUNTYTOENTERUPONiHE - - Z��;� A00VEA7ENTIONE�PROPEflTY PoR INSPECTqN PUHPOSES. - � COMMENTS � �6��--�,,,,-���P -- .:m PEAMI N PRIHn - - �Q 7��--�-�� i,�-s�,-t-.�� -- 1�� S 7U OFPERMI7TEE - DATE y �, :',_, RECPL N0. 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