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HomeMy WebLinkAbout12693 ^ �� CITY OF DIAMOND BAR �`� I DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVIC�S /�" 1 21b60 E.Capley Drive Suite 190 !�� (909)860-3195 Fax(909)861-31 t7 �-- PRESS ���'9^"� BUILDING PERMIT APPLICATION FIRMLY Q DDRESS ��J Z� IJ�,� ��`I`�' 1� 2 � P/C >- APPLICATION ,.-Z� PERMIT o DATE � ✓. NUMBER � �# ' TYPE OCC � � APN L� TRACT D TEE CONST. GROUP � O OWNER ! � ' �G i p ADD ESS � �, ZONING SETBACKS 3 Z CITY ZIP�� TEL`� f3._��VI FRONT _ RW U � g APpLICANT TEL. L REAR � � Z SIDEJSIQE STREET RW p_ � � CONTRACT�R � - ` J� 1��, SIDE �� AD ESS � C�N� �. ZIP��� TEL'� �2Z 2- PROPOSED USE � w ARCH/ENG/ , z' DESIGNER � � ADDRESS NO.DWEL. N0. Np. � � G�N ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATlON -O� OWNER-BUILDER DECIARATION� SFWA�D/REM � p. I MEREBY AFflRM UNDEq PENALN OF PEfLNRY THAT 1 AM EXEMPT FROM THE CONTRACTORS U- G8(3JB/CBfpOfl � U.� CENSEIAWFOHTHEFOILOWINGREASqY(SEC.7031.56USINESSAN�PROFESSIONSCODE:ANYqTYOR �: (n CWMYWHICHREWIRES0.PERMITTOCON57AUCT,AiTER,IMPqOVE.�EMOLISH,OqpEPAIRAM'STFLIC- PaliO/D6Ck 1 w. nAE,PRbR TO ITS ISSUANCE,AL50 REOUIHES THE APPLICANT FOR SUCH PEi1M1T TO FILE A S�GNEp : W � �.. STATEME4T TNAT HE OR SHE IS LICENSEO PURSUANT TU THE PROVISIONS OF THE CONTRALTORS.U- . CENSE LAW(CNAPTEp 9(COMMENCINO NNTH SECTDN�Wo)Oi OIVISION 30F THE 9USINE55 AN�PRO- � �' POOVSpd � PESSIONSCODE)ORTHATHEOR9HEISEXEMPTTHEREFROMANDTHEBASISFOPhIEALLEGEDE%EMP- � �V� T�IXJ.A4VVIOU710NOFSECilON7031.5BVANYA7PLICpNTFDqAPEFMRSUBJECTSTHEAPPUCAMTTO ;-.Z _R8-ROO� ,.2�� � �,- AdV�LPENALNOFNOTMOiiETHANFIUEHUNOAEDDOLLARS(f5a0).): � - ❑I,ASOYMEROfTHEPROPERN,ORMVEMPLOYEESWITNWAGESASTHEIRSOLECOMPENSATiON, � 0 COfnI1lBfLial . � �.�; iY1LL DD 7HE WOAK,AND�FiE STRUCTUftE IS NOT MTENOEO OR OFFEREO fOR SALE(SEC.7040,BUSI� �� � NESS PND PROFESSfONS CO�E:THE CONTpACTORS LICENSE IAW�OES NOT APPLY TO AN OWNEfl OF ��'. PROPERNWHOBUItD50RIMPROVES7HEREON,ANDWHODDESSUCHWORKHIMSELFORHERSELFOR ��� � �.CC. 711fl0UGN MIS OR MER0IYN EMPLOYEES,PR�VIOED TH/T SUCH IMPROVEMENTSARE NOT INTEN�EOOR 'm -W' OFFEREOFOqS/LLE.IF,HOWEVERINEBUILDINGORIMPflOVEMENTISSIXDWRHiNONEYEAROFCOMPLE- ��Z•_ TION,TtiE OWNER�BURDER WILL HAVE TNE BUR�EN OF PROVING TNAT NE OR SHE OID NOT Rllll O OR -� ..� IMPFOVEFORTHEPIIflPO5EOP5N.E�. � - � — `y,�. ❑I.ASOWNEROfTHEPROPER7Y,AMEXCLUSIVELYCONTRAC7INGWITNLICENSEDCONTqqCTOF�S - .W -TO CQN6TRUCT THE PROlECT(SEC.7oU,BIJSINESS AND PROFESSIONS CO�F:THE CQ�TPAC70RS LI- V2IU8tI0t1 ' � ADJ.AREA � -CENSEUW�OESNOTAPPLYTOANOWNEqOFAPROP[R7VWHOBUiLDSORIMPftOVESTHEPEON,AND �`�' -KMO�N7RACTSWRSUCHPROJECTSW11}!ACOMRPCTOR(S)LICENSEDPURSUANTTOTHECONTRAG �QUANTITY DESCRIP710Iv FEE TOqS{1C�NSE LAW.J. Y; .Q�� ❑IAMIXEMPTUNOEflSEC. B.SP.C_FORTHISREh30N-- � Q �. `-' fl�.� "1 J ' Q S � LL. DAiE OWNER `�, }�— �a / .:Z- U �T �'. 'Qi'9 o� UCENSED CONTSiAC70SiS DECl.ARA'iIOM ��--. W �/,,y�� �~ ' �Y�7 F'� � -��� 1 HEREBY RFFIRM UN�ER PENALN OF PERJURY THAT i p1A IICF,NSED UNOER PROVISIONS OF CHAPTER _.� � ., �I� �� (].,� Y(GOMMENCINO WITH SECTIqY'loao)OF DIYISION 3 OFTHE OUS:NFSS ANO PROFESSIONS COOE.AM1iD .: Z _�C'� t4Y UCENSE IS IN FULL FOfiCE AND EFPECi. �._ m { ltJ ! 'J _] _�_ LICENSE CLASS � — LIC-NO. S.`. `� �,.j -_ . # ��`U��. OATE �/� �L•�J �— � CONTRACT `=� d � `��. WORKEFS'COMPENSAT�ON DECLARATION J a � ..��� :.; U . N' I HEflEBY AFFWM UNDEH PENALTY OF PEiiJURY ONE OF THE PoLIAWING DECUMTKJ45: j .C/}_. .... z .. 3 .�;� _IHAVFMIDWILLMAINTAINACEHTIFlCATEOFCqhSENTNSELF-IfeSVREFORYtORKERS' �- � S COMPEIlSATION,ASPROVIDEDBVSECTION37o00FTHElAHORCO�E,FOHTHEPERFORMANCE ' U �_. OF7ME WORK FOR WHICH TNIS PERMIT IS ISSUE�. - :-. � �w _IHAVEANDWILLMAINTAINWOqKEpS'COMPENSATIONINSURANCE,ASPEqUIpEDBVSECTION I -� ,�p Q�. 37000FTkE LABOR CADE,FOR hIE PERFORMANCE OF THE WORN FOR WMICH TMIS PERMIT IS � �� ��/ ���' ISSUED.MY WORK' S'COMPENSATION INSURANCE CA,R�RIEig'�,`D POLICV NUMBER AR6� CONSTRUCTION � ��j�� cqaRieR � d-- �"l.�!��.Y PLAN REVIEW � - r - ` 4. aatcvNUMeea��S•' �' l.��f( nC��— ELECTRIC �. Q: (fWssECiaNNE�NoisE�MWLEtmoFTHEaEiU.arISFOaor�EHuwaEnrouAqS(S�m}opLEss}� PLUMBING W ��'Z I CERTIFYTHAT IN THE PERFOPMANCE OF THE WORK FOH WH�CH THIS PERMIT IS ISSUED,1 MECHANICAL . „_Cj�-,- .SNRIINOTEMP�OYANYPER50NINANYMANNERSOASTOAECOMFSUBJECTTO7HE ���(q�: WORKERS'CORiPENSATtONIAWSOfCALIfORVi0.F�NDAGREETHATIFtSHOUiDBECDAiE - - INSPECTIONFEE -SUBJECTTOTHEWORKERS'COAIPENSATIO PROVI51 SOFSECTION37000FTHE OR L ��o� GO�E,ISHALL�FyORTHWITHCOMPLYWITN SEPRO ISIONS. ISSUANCE �p:� DATE:-�I_�'3 `�� APPL�CANT: SMIP � W -- .� WARNING:FAILURETOSECUREWORKERS'COMPENSAT:ONCOVERAGEISUNLAWFUL,ANDSHAILeE ENERGYP/C _�(������Q ',�-: SU&IECTANEMPLOYERTOCRIMINlLL,PENALTIEEANDCIVILFINESUPTOONEHUNDREDTHOUSqNp iMl� OOI.LAflS(f7d0.000�.INADDITIONTOTHEGOSTOFCOMPEYSATION,DAMAGESASPROViDEDFOpIN ENERGYPERMIT �-.-�_ SECTION37080FTHELABORCODE,IMEREST,ANDAiTOFNEY'SFEES. RETENTION�TY��'i������� � -,�, CONSTRUCTION LENDINGAGENCY PRE-ALTFE�v����'�� .�.'�'�' .;.�.� IHEREBYAFFIflMUNOEFPENALNOFPEH.IUHVTHAiTMEREISACONSTFUGTIONLEiV01NGAGENCY � . Z: FOpTHEPERFORMANCEOFTHEWORKWPWHICHTHISPERMITiSISSUEO(SEC.3097,CIV.C.). 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