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HomeMy WebLinkAbout10369 (5) f,; � �: i �� ----/�`�- CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT .,,.� . 21660 E_Copiey Drive Suite 19D PRESS (909)860-3195 fax(909)A61•3117 ; �'""'� BUILDING PERMIT APPLICATION FIRMLY i N JOBSITE ,` ��j,/� l-;y,�j APPLICATION � PERMIT 7 P/C � � ADDRESS�`���� U•��:W 1�V {/Y)�?� _ DATE NUMBER �t./ # " o ISSUE TYPE OCC � °D �APN LOT TR{�CT _ DATE_ _CONST. GROUP � p OWNER L C.SO iJ o ADDRESS b AI�� � ZONING SETBACKS �XP1�7�� z ,CITY ZIP TEL. FRONT �f� ❑ _ i� `APPLICANT TEL. REAR LI__ �' S SIDE SIDE STREET • �,�j,W ❑ � ¢. l�l! C:1_ CONTRACTOR " � ADDR 5 � � � CITY ZIP TEL. PROPOSED USE � w ARCHlENG - 0 j� W DESIGNER NO.DWEL. NO. NO. 'f a ADDRESS_ UNITS STORIES BEDROOMS � � CITY _._ ZIP TEL. ' � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION J pC OWNER-BCILDER DECLARATION SFWADD/REM O p I HERE6V AFFIRM UNDER PENALTY OF PEFJURY 7MRT I AM E%f.MPT FROM THE CONTRACTOqS ll� Gef3J6lCdfpOli f W CENSELAWFORTHEfOLLOWINGREASON(SEC.7031.SBUSINESSANDPROfESSIONSCODE�ANVCITYON (n ' U COUNTYWFiiCHREDUIRESAPERMITTOCONSTRUCT,ALTEH,IMPHOYE,DF.MOUSH,ORREPAIRANYSTRUC- W PatiO/DBCI( �;{ w TURE.PflIOR TO ITS ISSVANCE.P150 FEQUIFES TNE APVI.ICANT FOR SIICH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PI1RSl1ANT TO THE PROVISIONS OF THE CONTfiACTORS LI• �3, � CENSE lAW(CNAPTER a(COMMENCING WITH SECTION Iaao)OF DIVISION 3 0F THE 6USINESS AND PR0- � POOUS(I8 p � FESSIONSCODEJORTHATHEORSHEI5EXEMPTTHEflEFROMANDTMFBA515FOflTHEALLEGEDEXEMP- (� � � TION.AkVVIOLA7lONOFSEC7I�N7a31.59VANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANiTO Z RB-R00} � AGVILPENALTY OF NOT MORE THAN FNE HUNOpF.D DOLLARS�SSoo)J: � ❑I,ASOWNEHOFTNEPROPERN,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 Commercial Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTENDEO OR OFFERED fOR SALE(SEC.7044,Bl1Sl- J H NE&S AND PqOFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT ACPLY TO AN OWNER OF l � PROPERTYWHOBUILDSORIMPflOVESTNEREON,AN�WHODDE55UCHWOfiKHIMSELFORHERSELFOR � j 2 THHWGHHISORHEROWNEMPLOYEES.PROVIDEOTFIATSUCHIMPROVEMENTSARENOTIN7ENDEDOR m � Q OFFEREOFOHSALE.IF,HOWEVER,THEBUILDIN60RIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- � Z TION,TNE OWNER�BUILDER WILL HAVE THF Bl1RDEN OF PROVINO THAT HE OH SHE DID NOT BUIID OR � IMPROVEFORTHEPURPOSEOFSRLF.). f.l l,AS OWNER OF THE PflOPERTV,AM E%CLU5IVELY CONTRACTING WITN LICENSED CANTRACTORS � TO CONSTHUCT THE PH0.JECf(SEC,7oaa,BUSMESS AND PFiOFESSIONS CODE:THE CqJTRACTORS LI- VdI112110f1 ADJ.AREA � W CEN5EUWUOESNOTAPPLYTOANOWNEROFAPROPLRTVWM09UIlOSORIMPROVESTHEREON,AND � WHOCONTRACTSFO�iSUCHPRQIECTSWITHACANTqACTOR�S�LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FE Y TORS LICENSE LAW.�. ,p�� � �I NA EXEIAD7 UNDER SEC.__ B.8 P.C.FOR THIS REASON Q _ 'LV!. jI� � � _._". ¢ '0� � /'[! � .3 � OATE"'""_ OWNER —"_y___'_'_"_' V Z + � LICENSED CONTRACI'ORS DECLARATION L f � 1 HEREBY AFFIRM UNDEfl PENALTY OF PEflJURY THAT I AM LICENSEO UNDER PROVISIONS UF CHAf'TER � � 9(COMMENCING WffH SEC"fION%000)OF OiVI510N 30F TME BUSINESS AND PROrcSSiONS COuc,iJrD Z _ ' X MY UCENSE IS IN FULL FOFCEAND EFFECT. � � "_' � �._, LICENSE CLASS_,___ IIC.NO. J 7 V DATE______.___ CONTRACTOR ______ 0. W j � WORKERS'COMPENSATION DECLARATION Q ; = U � IHEREBYRFflRMUNDERPEHALTYOFPEiUURYONEOFTHEFOLIOWINGDECURATIONS: ,.� � Z Q � � __IHAVEAN�WIILMAINTAINACEATIFICATEOFCANSENTTOSELF�INSl1REfORWOPKEPS' � � ' y COMPENSATION.ASPROVNEDBYSECTION31o00FTHELABORCODE,FORTHEPERFORMANCE U d OFTHEWORKFO(7WHICHTHISPERAAITISISSl1E0. � 3 W I HAVE AN�WILL MAINTAIN WOHK[HS'COMPENSA710N INSURANC'c,AS RE�UIRED BY SEC710N � Q vaoOFTHELABORCODE,FORTHEPERF�RMA'JCEOFTHEWORKFORWHICHTHISPERMITIS _------ ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER PND POLICY NUMBER ARE: CONSTRUCTION — .� j cnaaiea_..._.........__ PLAN HEVIEW � z POLICV NUMBER . _._ ELECTRIC _— L Q � 0 (IHISSECf10NNEmNOTBE00MfiEfEDOF7HEPERMfTISP7RIXJEMN�DFiFDD0UM5(StOo�ORLE55} PLUMBING . --- W� MECHANICAI Z ICERTIFYTHATINTHEPERFOflMANCEOFTHEWORKFORWHICHTHISPERMITI5155UED,l (}� SHAIL NOT EMPLOY ANY PEfl50N IN ANY MANNEF SOAS TO BECOME SU&IECTTO THE [�,•'_;+. f�� �� ,j �.; � '� � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGfiEE?HAT IF I SNCHILD BECOME IN5PECTION FEE . d .m•��� SUBJECTTOTHEWORKERS'COAIPENSATI�NPflOVISIONSOFSECTION97000FTHElABOH �''� � I'� 4 � CADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE �' __, � � SMIP � p DATE:___ APPLICANT: _____________. �y�p ---'— w ENERGY P/C �A dl [1 Il 1�TM4/ J WARNING FAIWRE TO SECURE WORKEfiS'GOMPENSATION COVERAGE IS UNLAWFUL,AfJD SHALL BE ��y��+ LL SUBJECTANEMPLOYERTOCRIMINALPENpL71ESAN�CIVILFINESUPTOONEHUNDFEUTFiOUSAND ENERGYPERMIT '" � ' OOLURS(5100.oW),INADDITION TOTHE C0.ST OF COMPEN6ATION,DAMAGES AS PROVIDED FOR IN � 5ECTION37080FTHELABORCODE.INTEREST,�N�ATTOflNEV'5FEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IMEREBVAFFlHMUNDERPENALTYOFPEflJURYTHATTHEFEISACONSTRUCTIONlLN01NGAGENCY d FOR THE PER(-0RMANCE OFTHE WORK WR WHICH 7HI5 PERMIT IS ISSUEO(SEC.3097,CIV.C.). -���- — Z W --------- � LENOER'SNAME_ ___.____ ____ F— LEN�EIYSADDRESS ._._.,___ _._.- W ICERTIFYTHFTINAVEREADTHISAPPLICATIDNANDSTATETNATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � I A6REE TO fAMPLV WITH ALL CIT/AND COUNTY OROINANGES AND S7ATE lAWS flELATING TO BUILOING �� CONSTRUCTION,AND NEREBVAUiHORRE REPRESEMATIVES OFTHIS COl1NTV TO[NTEFl t1PON THE Z ABOVE�MENTIONED PROPEflTV FOH INSPECTION PUPPOSES. COMMENTS_._,___ � N C UL or� -- � - m PENMITTEENAM INT) _ Q ^ —___ � y //[..— ... /��i14 WvV r f/) SIaNR7UR ERMITTEE DATE � � RECPT.� C _ PAID BV ___ VALIDATION, _ I ~ WHITE--0epartment Copy,YELLOW—�inance Copy,PINK—Assessor Copy,GO ENROD—File Copy,GREEN—ApplMant's Copy � � ,. w.. .�.�.�_..._. _. .___ �--�-� e r � � .. . -� � "�' I I I us.n, � -rs �+,� -n � in v>E � � ca � m :n�a � � ss -n �y��i--i va �y m c� � �� � z�2iz�� ,°Dn m � r"�� � T+ � al0 DIO Gla Q'� T�ID �s�m G�,, a n'�� n�� rla �. r- . 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