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HomeMy WebLinkAbout13189 (16) � �� CITY OF DIAMOND BAR �'~_ �`� ---�� — DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES'' -" ^ ` � 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)8613117 PRESS � ����A���� BUILDIIVG PERMIT APPLICATION _ . FIRMLY � JOBSITE APPIICATION` PERMIT l �! P/ � o ADDRESS �3��J� �e'�L�Pe� ��• O Z'� DATE NUMBERJ�� # o ISSUE TYPE C � °r APN LOT TRACT DATE CBNST. GROUP � p OWNER �.V<<h M+�-�0.4,� �vV�YEZ u" ADDRESS Z3�S�i ��..COv�,a {� ZONING SETBACKS � z GTY D�RnnD�d $�4� ZIP����� TEL.9C�- {D��3 FRONT RW ❑ � $ APPLICANT 1 r--u��., t�w.ta.n TEL. `` '� SfDE/51DE STREET RW � � � CONTRACTOR SIDE ❑ � o CDDRESS ZIP TEL. PROPOSED USE �+^��4� rvv � w ARCH/ENG/ z DESIGNER NO.DWEL. NO. O. d. ADDRESS � � UNITS STORIES BEDROOMS tt � CI1Y ZIP TEL. � N; DES IPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � .,�WNER-BUILDER D�CLARATION SF ADD REM � O -� ,� 1 HEREBY AFFlRM UNDER PENALTY OF PERJURV TMAT 1 AM EXEMPT FROM TNE CONTRACTORS ll - GBlO J0/C9fPOfI -W: CENSEIAWfORTHEFOLLOWMGREASON(SEC.7031.58USINESSAN��ROFESSIONSCODE:ANYCITYOR (n -U: COUNTYWHICHRE�UIRESAPEF#dITTOCO�STRUCT,ALTEH.IMPROVE,DEMOLISH,ORREGAIRANVSTHUC- � W P8I10/DBCK k ��' NflE,PRIOR TO ITS ISSUANCE.AL50 REQUIflES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED � W � �; STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTftAC70R5 LI� CENSELAW�CHAPTER B(COlAA�ENCING WITH SECTION 7000)OF DIVIS!ON 30G THE fiU51NESS AND PA.O- " � POOUSpB -� PESSqNSCODEjOflTHATHEOR5HEi5E%EMPTTFIEHEPROMANOTHEBASISFORiHEALLEGEDEXEMP- � . TION.ANYVIOI.ATIONOFSECTION7031.SBYANYAPPLICMITFORAPERM175U8JECTSTHEAPPLiCANTTO ���.Z Re-Roof _� ��' ACMLPENALiVOFNOTMORETHANFIVEHUN�qEOOOLLAFS(S5o0).): _ ,:o_; ❑I,ASOWNEROiTHEPROPERT/,OFMYEMPLAYEESWITHWAGESASTHEIRSOLECOMPENSATION, - � Commerciai ,:Z-:. WILL00 THE WOPoC ANU THE STRUCTURE IS NOT INTENOEO OR OFFERED FOfl SAIE(SEC.704a,BU51- � J ,� �--, NESSAND PflOFESSIONS COOE:THE COMRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF + � " . PROpERTYYAiOBU�LA30RIMPROVEShIEREINJ,AN0Yhi0O0E5SUCHWOflKHIMSEIFORHERSELFOR i? '-� -��_ hIRIX1GHHI50qHEAOKRJENPLOYEES,PHOVIDEDTHRTSUC171MPROVEMENTSAHENOTINTENDE00R '. -W. OFFEREDWRSALEIF,HOWEVER,THEBUILOINGORIMPRaVEM6YTISSOLOWITHiNONEYEAROFCOMPLE- ; �-- -� TIOPt,THE OWPlER-BURAER WILL HAVE 7HE BUftDEN-OF PROVING THAT HE OR SHE OID NOT BUItD OR. . ..... _ . . . . . . ... . _ � ���-Z- -IMPHOVEWR7MEPURPOSEOFSAL�. . _'- ❑I,ASOWNEHOF�'fHEPROPERTV.AME%CLUSIVELYCONTRACTWGWRHLICE4SEDC0,'7TRAC70q5 �-- TO CONSTRUCT THE PRQIECT(SEC.7oM,BUSINE55 AND PROFESSIONS CODE:TFIE CONiRACTORS LI- VelU8fi0� � � ADJ.AREA --W� -CENSEUWDOESNOTAPPLYTOANOWNEROFAPflOPERNWHO8U1LD50RIMPPOVESTNEREON.AND �-�----WlIOCONTRpCTSFORSl1CNPRQIECT5WITHACO!JTflACTOR(S)LICENSEDPUPSUANTTOTHECONTflAF pUANTiTY DESCRIPTION FEE - :TOpSIJCENSELAW.i. .:�._ �.: J , :O� - ❑1 AM EXEMPT UNDER SEC. B.&P.C.FOF THIS REASON� � Q �, ` ¢ i 9� �p; � �L.-1�� ��� :�-.z4 DATE �C�'?-�-4 OWAIEF W �.� - _-o . LICENSED CONTRACTORS DECLARATION �j -�-� IHEREBYAfFIRMUNOERPENALTYOFPERJURViHATIAMUCENSEDUNDERPROVI510N50FCHAPTEfl _ � �- _d- .9(GOMMENCNV(3WITHSECTlON7o0o)OFDIVISION30FTHEBUSINESSANOPROFESSIOhSCODE.AND . Z ::X�-1AYUCENBEISINFlJLLFORCEANDEfFECT. m LL! , �. '0�:. LICENSE CLASS LIC.NO. - :, J:. -_:.�. 3V DATE GONTRACTOR ::�d� � W= ' '� : .WORKERS'COMPENSATION DECLRRATION - J i__ _ . � .. . . �- �� 1 HEREBV AFFIRM UN�ER PE:JALTY Of PERIURV ONEOFhIE FOLLOWING DECLAFlATIONS: �- v ;j -� � � e Q -' --�_- IHAVEANDWLLMNINTAINACERTIFICATEOFCOMSENTTOSEIF-R15UNEFORWORKERS' - _ ��� ,`�_: COfdPENSATION,ASPROVIDEDBYSECTIQ�37000FTHElABORCODE,FOftTHEPEFFORMANCE- _: W - OF7}IE WORK FOR WFiICH 7MI5 PEflMIT iS ISSUED. - g � 0. =�' _I MAVE AN�WILLMAINTAIN WORKERS'COMPENSATION IN9URANCE,AS REQUIREDBY SECTION PA -:Q: 370o OFTHE LABOR CODE.FORTHE PERFORMANCE OFTHE WOP.K f-0R WMICH THIS PEfiMIT IS v' � ���' -�=- ISSl1ED.MYWORKERS'COMPENSATIONINSl1RANCECAFRIEflANDPOLICYNUMBERARE: CONSTRUCTION 6 -�d� PLAN REVIEW � � _::�:. CAqqIEP � � � � � Of aaICYNUMBER _ ELECTRIC .:_�Y (nuss[cr�r�nareEoa.��meFn�aEw,qrsc�or�eHuwAE000unl�s�siro)oa�Ess� PLUMBING -W; MECHANICAL � ,-Z, I CERTIFYTHAT IN THE PERFOPMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 -- ('j.: .SHALLNOTEMPLOYqNYPEA50NiNANYMANNER50A5TO0ECAMESUBJECTTOiHE- - - ,�: - WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOAGREETMATIFISHOULOBECAME - -INSPECTIONFEE - ' SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR � --F—: ISSUANCE --'�-�� .���� .:� COOE.ISHALLFORTHWITHCAMPLYWI7HTHOSEPROVISIONS. /� '.�: - SMIP _���� �•�V :p._ Dp7E: - APPLICANT. . . 'W- ENERGY P/C %�" �~ -J WAflNINd:FAILUflETO SECURE WORKEqS'COMPENSATION CAVERAGE IS UNLAWFl1L.AND SHALLBE �y, + - :�y; SU&IECTANEMPLOYERTOCRIMINALPENALTIE3ANOCIVILFMESUPTOONGHUNDREDTHOUSANO ENERGYPERMIT _,.._____._�` ` _ -- �.�FT�I` DOLLAflS(flao.oa0�.IN ADDITION TO THE COST OF COMPENSATION,�AMAGES AS PHOVIDED FOR IN - �-J- SECTION 97oe OF iHE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: - � -'��"�� � -�'.. CONSTRUCTIONLENDINGAGENCY -P -ALTF�E� � 's��' ���"��� l L. . � ,��._ i HEREBV AFFIRM UNDER PENALTYOF PERIURV THAT THERE I5 A CONSTflUCTiON LENDING AGENCY . J y '�� � FORTHEPERf-0fiMANCEOFTHEWORKWRWHICHTHISPERMITISISSUE�(SEC.3o9i,CN.C.). �'T-�� � Z-: /✓ W, � LEN�EH'S NAME __ � ---H� LENDEH'SAWFESS ---a� ICEFTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHRTiHEABOVE1NFOftMATIONISCORRECL `. TOTAL FEES W- IAGREE7000MPLVWITHA�LCITYPNDCOUNNOR�INANCESANOS7ATELAWSPELATINGTOBUILDWG � GONSTflUCTION,ANDMEREBYAUiFIOflIZEREPFESENTATNESOFTHISCOUNNTOENTERUPONTHE �'yy//���' � _Z- ABOVEMENTIONEOPROPEHTYFORINSPECTIDNPURPOSES. COMMENTS����.� 0 y� � /�/'y ---�-- �WlV\ AD�/�{rY47 . � � '-m ,DERM�TTE�E IPRINn � ' -� ` . �,� / 1D—2.3�1� a �.� SIGNATUREOFPERAIITTEE DATE RECPT.NO. 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