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HomeMy WebLinkAbout12823 (13) I CITY OF DIAMOND BAR � ----- �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � � _. �� 2166U E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-311% PRESS � `"9t"��� BUILDING PERMIT APPLICATION FIRMIY o ODRfESS ��Z�I �,�}L''R-A! S� APPLICATION --Z��-� NUMB Rl��#/C DATE �- m ISSUE TYPE OCC APN LOT ._ TRACT __ DATE CONST. GROUP p OWNER i.�-�1�-� rl:, _ � ADDRESS�11 ti'l 1oA-A-A! J� ZONING SETBACKS Z CITY I71� ZIP� TEL. Q J�.S�/'�g'`7'�} REART RW rnj_ g APPLICANT TEL. SIDE/SIDE STREET RW CJ � CON7RACTOR��1 � �- /��- SIDE _ __ __ I:� ____ Q ADDRE S fl36L �ifP/�iiV 1r.q, ;r�1�+'� � CITY�61�tN U�co� Jd�yl TEL. �11� 5���-�rS� PROPOSEDUSE— - --.-- o ARCH/ENG/ W DESIGNER — NO.DWEL. NO. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS _ � cn DESCRIPTIDN SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlREM O I HEREBV AFFIRM UNDER PENALr`/OF PER0.IRY THAT I AU EXEMPT FROM TN[Cq 1TRACTORS LI- G8f8QB/CBfPOfS W CENSELAWFORTHEFOU_OWINGREASON(SEC.�031.5BUSINESSANOPfiOFE5510N5CODE:ANYCITYOfi (n C.� WUNT'WIi1CHREWIRESAPERNIT70C0457RUCT.ALTERJMPROVF.,OEMOLISH.ORREPAIpANVSTRUC- W patio/DBCk � IURE,PRiOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SLICH PERMIT TO FILE A SIGNED W � STATEMENT TNAT NE Oq SHE IS UCENSED PURSl1ANT TO THE PROVISIONS OF THE CONTRAC70fi3 LI� CENSE LAW(CHAPrER 8(COMMENCINa WITH SECTION 7000)OF DIVISION 3 OF TME BUSINESS AND PRO- � POOUSp8 FESSIOkS�E�ORTHATHEORSHEISEXEMPTTHEREFROMANUTHE0A515FORTHEALLEGEDE%EMP- (� TION.ANYVKKATIONOFSECTION7031.SBYIINYAPPLICRNI'FORAVEHMI75UBJECTSTHEAPPUCANTTO Z Re-Roof � A CML PENAL7Y OF NOT MORE T}WN FIVE HIINDREO�OLIARS�5500).): � ❑I,ASOWNEROFTHEPi70PERTY,ORMYEMPLOYEESWITNWpGESASTHFIq50LFCAMPENSATION, ❑ COmme�Cidl ' N7LL00 THE WORK,AND TNE STRUCTURE IS NOT IYTEND'c0 OR OFFERED FOR SALE(SEC.%044,BUSI� J �N NESS AND PflOFESSIONS CO�E:THE CANTRACTORS LICENSE LAW�OLS NOT APPLY TO qN OWNER OF ' � PROPERTY W/i0 6111LD50R IMPROVES THEREON,AND WHO OOES SI1CH W'ORK HIMSELF OP HERSELF OR Q THROUGHHISORHERONTIEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENT8ARENOTINTF.NDE.�OR m O; OFFEREDfORSALE.IF,NOWEVER,TMEBUil01NGORI.MPROYEMENTISSOLDWITHINONEYEAROFCOMPL[- _ Z TION,THE OWNER-BUILOEN Wll.l.HAVE TME BURDFN OF PROV!NG THAT HE OR SNE 0!f7 NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE). � Cl I,AS OWNER OF THE PROPENYY,AM E%G.USIVELY CANTRACTMIG WRM L'C.ENSEU CONTRqCTORS 70 CDNSTRl1C7 THE PR0.IECT(SEC.70M.BUSINFSS AND VROFESSIONS CODE:THE CONTPACTORS ll� Valu2tion ,.,.._ADJ.AREA ____,...._,_..,______ W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUIIOSORIMPROVESTHEREON,AND � ��� VRiOCONTRACTSFORSUCHPRWEC75WITHACONTRACTOR�S)LICENSEDPUHSUANTIOTHECONTqAC- QUANTITY DESCRIPTION FEE Y TORSLICENSEL�W.�. � Q CJ I AM E%EMPT UNDER SEC. __ �.&P.G FORTHIS REASON Q 3' ----- — — � LL -- - -- --- — a� •- DATE _OWNER__ ____,_. � �. W .r LICENSED CONTFACTOFS DECLAR.4TION �u I � IHER[BVAFFIRMIINDERPENALTYOFPERJLIRYTHATIAMLICEN3EDL1N0ERPROVISiONSOFCHAPT[fi �, i .,�� 9(COAIMENCING WITH SECTION 7000)DF DNISION 30F TNE�USINESSAND PROFESSIUNS COOF:,ANU Z �X MY LICENSE IS IN NLI.FORCE AND EFFFCT. m '�. �o. UCENSE CLASS_��_�i_ LIC.NO.___ S f�I��_._...� ; . ^�j _ ... !,V. DATE�z`��_'7 a CONTRACTOR � WORKERS'COMPENSA710N�ECL4RATION !r� � ,d r�,`/ !�J J �G�G' ` �N� IHEflEBYAFFIRMUNDEflPENALTYOFPERIURYOYEOFTHEFOLLOWINaOEGLqRAT� � �, i ¢ �--�� pN� �M , � _IHAV[ANDWILLMAINTAINACcRTIFICATEOFCOYSENTTOSELF-INSUREFORWORKE9S' _ �� COMPENSATION,AS PROVI�LD BY SECYION 3700 OF THE LABOfl CODE,FOR THE PERFORIf.AKCE �U OF THE WORK FOR WHICH THIS PF.flMIT I5 155UED. � ... 'W' � i HAVE PND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,A5 RE�UIRED BY SECT!O� O 37oaGFTMEI.ABORCO�E.FORTHEPERFOR!AANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MV WDRKERS'WMPENSATION INSURANCE CARRIER AND POLICY NUMBER AflE: CONSTFdUCTION � . /� ,�/ "'""" .....'—"'_ _ j� caRaiEn_y"��I4L�Nw _ F�lli� LANREVIEW '. . ��n _._...__...._.._------- � .Q POLICV NUMBEfl M�.r/l'.. �S_��_�___C�_.�__ . ELECTRIC ..__._..__.__ .�0 (IHISSECiIOVNE�N0T9[OJMPtFfE�OFTF+Ef'ERMRISFOfiONEHUrDREO (51001�LESS). PLUMBING _._.,_._ r'- W "'r'' Z I CEflTIFV THAT IN THE PEFFORMANCE OF THE WOflK FOfl WHICH TFiIS PERMIT IS ISSUED,I jd.ECHA _.._,_ 6 �,(}. SHALLNOiEMPLOYANYPERSONINANYMANNENSDASTO6ECOM[S119J[f.TTOTH[ 8 �y ' "�" WOflKERS'COMPENSA7'IONLAWSOFCAL�FOflNIA,ANDAGREE7HATIFIS1i0UlD0ECOME INSPECTIONFEE �/$�i6 _„__,__ _,. SU8IECTTOTHEWORKF.fiS'COMPENSATION VISIONSOFSECTION37000FTHELA80fl -� COOE.ISNA4FOHTHWITHCOMPLYWIhiTO PROVISIO . / JI.�,_._ ISSUANCE _. _�./ '�^� p �P SMIP . .:`p. OATE: �J.I'� ? APPLICANT: _ ' J� .'__....._. _.__..."...-.........__._".._ � l ENERGV P/C �J WARNIN�:FAILUFE TO SECURF WORKF.RS'COMPENSATION CWERAGE IS UNLAWFUL,RND SHAIL BE "'-""'- --��- �--�------ --- ��'� SUQIECTANEMPLOVEFTOCRIMINALPENAL7IF.SANOCIVILFMESU�TODNEHl1NUHE�THOl1SAk� ENERGYPERMIT �OLLA(i5(S1 oo.00D).IN AODITbN TO THE COST OF COMPENSATION,DAMAGFS AS PROVIUED FOR IN TV y'��[p$(^y�7�'y A�g-- ,-� SFCTION370AOFTHFLABORCODE.INTEREST,�N[1ATTOHNEY'SFFES. RETENTIONFEE: ��^"^�OFLT+!!�]�L,�YlV�1cVL�!'1l\ .d� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ��v`'�j�i!`'A . ;0 '------�-------�----- ' �. I HEREBYAFFIRM UNDF.R P[NALTY OF PERJURY THAT THERE I5 A CONSTqUCTION LEN�ING AGENCY ��- FOR THE PERf-0HMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEG 7087,CIV.C.�. '�--- -�-—""""""'�-----'---�----�—— Z . .W —.—'—"..___"'_'.'__ -� LENDEWSNAME "_"'_"_—___'__.._...._'_"_"—' F— LENDER'SADDRE55,,,,..___... ��' ICFRTIFYTHATIHAVEflEADTHISAPPLICATIONANDSTAT[THATTHEAOOVEINFONMATIONISCORpECT. TOTAL FEES y 'W I AGREE TO COMPLY WITH PLL CITV AN�COUNTY ORDINANCESAND STATE LAWS FELATING T00UILDING � ��� CANSTRUCTION,AND HEREBY AUiHORIZE REPR[SFNTATIVES OF THIS CDUNTY TO ENTEflUPON THE Z'� �BOVE-MENTIONF.DPROPEHNFOFINSPECTIONPURPOSES, COMMENTS � —~ ��s,� �_/�i� //Y - - -- _ ---------- - � -- ---- m PERMITTE (PRINT) c�_n '" , �Q / � -1./-`� --...- -- ---- ��� SICjN -OFPEfiMI " DATE ,.= d RECPT.NO. PAIDBY ____ VALI�ATION "~� WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENHO�File Copy,GREEN-ApplicanPs Copy P�,p�3 —t x r � �..,_ i �...�. — � _ T r � ��,,,�y . � A x � �''m#'r � �n { A f� � � 1 � 1 e � 5 .� � , I ��f� Y�#9.t f �. t ' ! . �� .i �y i, � : � . � I , � �k ���Y� r �i : ! � . � F I 7 'I� J) I'. .� dl � �!, �i���� �.u� ��.� x ti � �I . S . .r i ��� �.�� r� y � + �, �� �: e �`�'� �`���'#�. �: a , ,�� i r r :� r i I i t�€� �� ,�i � '.� � _� � aa v� y ��p�f{-������ � ���€[ � � � � � � � �� i� I:.� i � '�,, . 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