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HomeMy WebLinkAbout17464 (17) J� CITY OF DIAMOND BAR EX P I R E D � DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES 21825 E.Copicy Drive (909)860-3195Fax(909)861-3117 JUN 18 2002 PRESS ��''*�� BUILDING PERMIT APPLICATION FIRMLY o� JOBSITE '/ APPLICATION / PERMIT P!C ADDRESS o�Q''Y3,� Pt�p 2�► � DATE_ �Z`h —O ( NUMBER_�7�b�- p � APN T TRACT D TEE �� � � �"D( CONST. GROUP p OWNER "' ADDRES � � 2. ZONING SETBACKS gCITY � h ZI TEL % ' FRONT RW ❑ APPLICANT 1� C.�- TEL. REAR ❑ � SIDE/SIDE STREET RW p a� CONTAACTOR SIDE ❑ o CDDRESS ZIP TEL PROPOSEDUSE C��'h�Ca-� 'i- o ARCH/ENG/ z DESIGNER w N0.DWEL N0. NO. a ADDRESS � CIN ZIP TEL UNITS STORIES BEDROOMS � cn OESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p 1 HEREBY AFFlRM UNDER PENALTV OF PE0.NRY THAT I AM EXEMPT fROM THE CONTMCTORS L4 Garaga/Carport W CENSEUWFORTMEFOIIOWIN6REA50N(SEG70J1.68USINESSANDPflOFE5510N5CODE:M7YCITYOR (A V COUHTYYYMIp7qE0UIRE511PERAIRTOWN57RUCT,AL7ERMVROYE,DEMOL15M,OHFEVNRANYSTRUG W P8110/DBCk � NRE PHqR TO RS ISSUANCE.AL50 REOUIHES THE APPLICANi FOR SUpi PERMIT TO FIIE A SIGNE� w .dr STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI• � � CENSEUW(CHAPTERY(COMMENCM6WITHSECTION7000lOFDINSION30F1HEBU51NE55ANDPRO� POOUSpB � FESSIONSCOD�ORTI/ATMEORSHEISE%EUPTTHEPEFHOAIANOTNEBAS15FORTHEALtE�EDEXEMP• (� TION.ANVVIOLATIONOFSECTION70�1.SBYANVAPPLICANTFORAVERAIITSUBJEMSMEADP��µNTTO Z Re-Roo1 ACMLiENALTY OF/pT MORE iHAN flVE MUNDFED�OLUfIS(f500�.} Z01,1150WNEHOFTHEOROPfRTY,ORMYEMGLOYEESYATHWAGESASTHEIRSOLECOMGENSATION, � Commercia� -� WILL DO THE WORIC AND 7HE SiRUC7URE IS NOT INTENDED OR OFFEREO FOR SA�E(SEG 10��,BUSI• J � NE55 ANO GFOFESSIONS CODE:THE CONTMCTORS UCENSE UW OOES NOT AVPLY TO AN OWNER OF = PROPEHiY NT10 BU4D5 OR MPROVES TNEREON,ANO VA10 DOES SUCH WONK HIMSEIF OR HERSELF OR Q THROU6MNISOflHEROMMEMPLOYEES,VROVIOEDTHAT5Up11A1PROVEIAEMSMENOTINTENOEDOR m � OFFEREOFORSFLEF,IIOWEVER7HEBU0.DPIGORIMPROYEMEMISSOIDWITMINONEYEAROFCOMPLE• Z TqN.THE OWNER�BUILOER ri1LL HAVE THE BURDEN OF VROVIN6 THAT HE OR SHE DID NOT BUILD OR = IMPROVEFORTHEPIIRP0.5EOFSALE} �0,IISOWNEROFTHEVROPERTY,AMEXCLUSNELVCANTMCTWWy ITHIICENSEDCONTMCTORS Q TO CIHS7RUCT iHE VR0.1EM(SEG70aI.BUSINESS AN6MOP6S9j6N5 CODE:TME CONTMCTORS LI- V31u8t10D AQI.AREA W CENSEUWDOESNOTMPLYTOANOWNEROFA�qOPERTY BUILDSORIMPROVESTHEHEON.AN� � VmOCONTMCTSFOR5Uq10ROJECT i AfAN� ICENSECPURSUNRTOT/ECOMMG OUANTITY DESCRIPTION FEE � TOHSUCENSEUW.). � O IAM EXEMPT NDER SEC B.�P.C.FOR THIS REASON Q � U LL � . DATE OWNER V � W F LICENSED CONTRACTORS DECLARATION W � IMEFEBVAFFIRNUNDERPENALT'OF7ERIURYT1AilAMLICEN5E0UNDERFROYI5qN50FC1uPTER � p„ Y(COMMENqN(iN'ITHSECTqN700a�OFOM510NJOFTNEBU51NE551WDPROFES510N5CO0E,AN0 Z `X MYLICENSEISNMLFONCEIW�EFFEC7. m � UCENSE CUSS UC.NO. j V DATE CONTMCTOR d W � WORKERS'COMPENSATIONDECLARATION ¢ —� �O ` �l y1 MEREBY AFFIIiM UNDER VENALTV OF PEtiIUM ONE OFTNE FOLLOWIN�DECLAMlI0N5: Z � � �IHAVEMlOVAILMAINTNNACERTIFICATEOFCONSEMTOSELF-INSUREFORWORKERS' _ COMPENSATION,AS PROVIOEO BYSECT70N i70o OF THE UBOR CODE FOR THE PERFORMANCE �U Q OF7HEWORKFORYMip1TH15PERMIT15155UE0. � � _IHAVEM10WIllM�MTAINWORNERS'C0IAFENSATIONINSURANCE,h5RE0UIREDBVSECTqN O 77ooOFT11ELABORCOOE,FORTMEPERFORMANCEOFTHEWORKiORMMipITHISPERAIITIS ISSVED.MY WOFKERS COMPENSATION INSURANCE CARFIER�N�POLICV NUMBER ME: CONSTRUCTION jGMRIER PLAN REVIEW � POLICY NUMBER � ELECTFIC � �nnssEcnwn�mwreem�s3FrmanEVEw.rrs�tt+Eia�moaius�s,m�oa� PLUMBING Z I CEHTIFY THAT N THE PERFORMANLE OFTHE WORK FOR WHICH iH15 PERMIT IS ISSUED.I MECHANICAL Z�S ("} SwLLLNOTEMPLOYM7YPER50NWANYMANNER50A5TOBECAMESUB1EGiTOTHE �/j NORKERS'COMPENSATpNU1W50FCALIFORNItiANDAGREETHATIF15110ULDBECOME INSPECTIONFEE S SU9JECTTOTNEWORKERS'COMCENSATqNYpOVI510N50F5ECTqN77000FTHEU00N CODE.1 SHALL FORTFM1NTH COMPLY WITH 7HOSE VPAVISIONS. ISSUANCE � SMIP ZS•�J'�� p DATE: APPLICANT. . JENERGY P/C �� » '� WARNINO:FAILURETOSECURE WORKERS'COMPENSATION COVERAGE ISUNUWM.AND SMALLBE � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCMLFINESUPTOONEHUNOREOTNOUSAND ENERGYPERMIT DOLuiiSlf 100.000).N ADDITION TO THE COST OF COMOENSATqN,DAMAGES AS PROVIDEO FOR IN � SEGTION770oOF7HELABORCODE,NTERESLANDATfORNEY'SFEES. RETENTIONFEE: ������ �� � oCONSTRUCTION LEND�NG AGENCY pqE-ALT FEE: � IHEREBYAFFIflMUNDERPENAITYOFPERIURYTHATTHEREISACONSTRUCTIONIENOWGACENCY __ FOR THE VERWRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.DaY7,CI¢C.�. Z --.1..'__..,�,.� LLl � LENOERS NAME � IENDER5A00RE5S � TOTAL FEES � (�0 W I CERTIFY T/UT I H�YE READTry�SJIPPC(GTION�GqSTAiE AT THE ABOVE INFORMATqN IS CARRELT. p. IAGREETOCOMPLYWITHA[CCITYANDCOUNTYOFD GESANDSTATEUWSRELATINGTOBU0.01NO � �. 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