HomeMy WebLinkAbout11364 (5) �
--��'�`�"`�-1 CTI'Y OF DIAMOND BAR
! COMMUNITY DEVELOFMENT 7�EPARTMENT � � ���
-.e. 21660 E.Copley Drive Suite 190 PRESS
(909)860-3195 Fax(909)861-3117
�"%"' BUILDING PERMIT APPLICATION FI RM LY
o A DRiESS� `�� 'V : C�� DATE'CATION ,� NUMB R �� #/C
ISSUE TYPE OCC
� � APN L T TRACT DATE CONST. GROUP
� OWNEA ��Q_ ��
� ADD SS � °�C � ZONING SETBACKS
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o APPLICANT � ` � . ' TEL.y�— A� REAR ❑
SIDE/SIDE STREET RW �
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� Q ADDRESS � �� �-
� CITY �_ ZIP ^ � TEL.��...F�-#�cG�S�{, PROPOSED USE
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i z DESIGNER NO.DWEL. NO. NO.
� a_ ADDRESS UNITS STORIES BEDROOMS
NCITY ZIP TEL.
� � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION '
�O- OWNER-BCILDER�ECLARATION SFR/ADD/REM
1 p- I HEHEBY AFFIHM UN�ER PENALTY OF PERJURV TMAT 1 A.M EXEMPT FROM THE CON7RACTOHS LI- G2f8Q2/CBIpOfi
� 'W CENSEL4WFORTHEFOLLOI'dMGPEASON(SEC.�a315Bl1SWESSAN�PFOFESS10N5CA�E:ANYCITVOR (n
3 � CAUNTYWI{ICIiREQUIRESAPCFIMITTOCONSTRUCT,AITER,IMPROVE,DEM.O�ISH,ORREPAIRANYSTRUC- W Pa[io/Deck
� .W. TUHE,PRIOR TO ITS ISSUANCE.PL50 RE�UIRES THE APPLICANT FOfl SL'CH PEftMIT TO FILE A SIGNED W
�� STATFMENT THAT HF OR SHE IS LICENSED PURSUANT TO THE PflOVI510YS OF THE CONTRACTORS ll-
j - CLNSE LAW(CHAPTER 9(COMMENCING VlITH SEC7104 7000)OF DIVISION 30F THE BUSMESS AND PR0- � Pool/Spa
; �- FESSIONSCADE)OFTNATHEORSHEISE%EMPTTHEREFROIdANDTHE6ASISFOPTHEALLEGEDEXE�dP-
� 0 710N.AtdvVIOLAT70NOFSECTION7o37.50YANYAPPLICANTFORAPERMITSU&1EC757HEAPPLICANTTO Z� RE-RoOf
F ACIVIL PENALTY OF NOT MOflE THAN FNE HUNDRED DOLLARS(5500).):
_O. ❑I,ASOWYEROFTHEPROPERN,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATIOY, Q COffIrtlOfClfll
� -_Z WILL DO THE WORK,ANO THE STfiUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC.7044,9USI- J .
NESSAND PPOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES hOT APPLY TO AN OWNER OF
� PROPEflNWHOeUILD50ftIMPflOVESTHEREON.ANOWHODOE55UCNV/OAKHIMSELFORHERSELFOR �
:[L THROUGHHISOqHEROWNEMPLOYEES,PFlOVIDE�THATSUCHIMPPOVEMENTSARENOTINTENDEDOR m
-W-. OFFEREDFORSALE.IF,HOWEVER,THEBUILDWGORIAAPROVEMENTISSOLOWITHINONEYEAROFCOMPLE- -
4 '�' TION,THE OWNEFi�BU1LDER WILL HAVE THE BURDEN OF PROVING THAT HE OR 51{E DID NbT OUILD OR
--Z- IMPROVEFORTHEPURPOSEOFSALE). - --
� GI,ASOWNEROFTHEPROPERTV,AMEXCLUSNEIYCONTpACTINGWITHIICENSE�CONTPACTORS
�-� TO CANSTRUCT THE PROJECT(SEC.�oa4,BUSIN[SS AND PPOFESSIONS CODE:THE CANTRACTORS LI- VdI11d11011 ADJ.AREA
�W CENSEUlW00E5NOTAPPLYTOANOWNEROFAPflOPERTYWHOBUILD50RIMPROVESTHEREON,AND
-�_ WHOCANTflACTSFORSUCHPPOJECTSWITHACANTRAC70R(S)UCENSE�PURSUANTTOTHECONTf7AC QUANTITY DESCRIPTION FEE
_Y_ TOFSLICENSEIAW.).
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,�. CIAMEXEMPTUNDERSEG B.&P.C,FORTHISREASON Q
� V
� LL F�-
- DATE OWNER U
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--,�, __ LICENSED CONTRACTORS DECIARATION - W
:�- I HEREBYAFFIRhA UN�ER PEYALTV OF PEP.JURV THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTEfl � F � '� � ��n , f I
:d.: 9(CJMMENCW�WiTHSECTION70bJ)OFDIViSION30F1HEBUSINE55ANDPROFESSiONSCADE,AND z - ���
-X--- MY LICENSE IS M Fl1LL FORCE AND EFFECT. m
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-�� LICENSE C SS i�c UC.NO. � �
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-.�- � WORKERS'COMPENSATION DECLARATION Q
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�-�- I HEREBYAFFIflM UNDER PENALTY OF PERJUFlY ONE OFTHE FOLLOWING DECLARATIONS:
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�� I HAVE AND WILL MAINTAIN ACERiIFICATE Of CONSENTTO SELF-INSURE FOR WORKERS' _ - � -
� -Z- COMPENSATION,ASPflOVIDE06YSEGTION3]OOOFTHEIABORGODE,FORTH'cPEHFORMANCE U - �
�¢- OF THE WORK FOR WHICH THIS PERAAIT IS ISSUEO. �
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W- I HAVF AND WILL MAINTAIN WOfiKERS'COMPENSATION INSURANCE.AS RE�SIIRED BY SECTION
�- ,Q_ - 3�ooOFTHELABORCODE,FOflTHEPERFORMANCEOFTHEWORKFORWHiCHTHISPE[iM1TIS
ISSUEO.MYW�C ERS' DMP SATIONINSURANCECAflFIERANUPOL'GYNUMdEHAHE: CONSTRUCTION
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� -Z_. POLICY NUMBER__ ����2 �y��C�1 i ELECTRIC
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( ;�� (IHISSECTK)NNEmNOTBECOMPLETEDOFiHEVtNhYTISFORIXJEHU�REOD�f.IARS(57C0)ORLESS4 PLUMBING f.y _
.-� -W. . . . .
.z IGEflTIFYTHATMTHEPERFORMANGEOFTHEWORKPoflWHICHTHISPERMITISISSUE�,I MECHANICAL
-�;�- SHALLNOTEMP�OVANVPERSONINANYMANNERSDASTOBECANESUBJECTTOTHE
-_� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGReETHATiFISHOL'LDBECOlAE INSPECTIONFEE . -
- SU9JECiTOTHEWORKERS'CA!APENSATIONPROVISIONSOFSECTiON3 OOFTH LABOR ' �
,�, CO�E.ISHA FORT�HW/ITHCQ`.1PLYWITHTHO PROVISIONS ISSUANCE r .�.��'
�p. DATE:��U APPLICANT: - � ._ . SMIP . �, .
W- -� ---�-�--�--�� ENERGYP/C
.J_. WAFNINQ:FAIL RE SECURE WOFKERS'COMPENSATION CO4ERAGE IS UNLAWFUL,AND SMPLL BE
..� SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES ANO CIVIL F1NES 11P TOONE HUNORED THOUSAND ENERGY PERMIT
DOLLARS(5700.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PflOVIDED FOF IN �p� -�--�--- -
�J SECTION37080FTHELA60RCODE,INTEREST,ANDATTOFNEY'SFEES. RETENTIONFEE: __�VF�
� .�
-;� CONSTFIUCTION LENDING AGENCY PRE-ALT FEE
0
��- IHEREBYAFFlflMUNDERPENALTYOfPERJURVTMATTHEREISACONSTRUCTIONLENDINGAGENCY
��� FOR THE PERFOflMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED{SEC.3097,CIV.C.). � �---
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.��_ LENOER'S NAME
1_' LENDER'S A�DiiE55
���. IGEHTIFYTHATIHAVEREADTHISAPPUGATIONANDSTATETHATTHEABOVEINFOflMATIONISCOflRECT. TOTAL FEES �� �'��
W I AGREE TO CAMPLY WITH ALL CIN AND COUNTY OFDINAYCES AND STATE lAWS RELATING T0 OUILDING
� CONSTRUCTION,AND HERE6VAUTHORIZE REVFESENTATIVES OFTHIS COUNTV TO ENTEp UPO4 THE
_,Z-._ ABOVE�MENTIONEDPROPER.VFORINSPEC O�l'PURPO�Es. COMMENTS
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