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HomeMy WebLinkAbout16057 (22) _.A., ...__.,,�_ , ,. M.,.;»�,e,�-, . .,...�,..__��" _ .. . � .. ,.� �,,�'�'��- ` CITY OF DIAMOND BAR /� / ---��-- DEPARTMENT OF COMMUNITY 8z DEVELOPMENT SERVICES �6�J d� � l 4 ,� 21660 E.Copley Drive Suite 190 � PR ESS (909)860-3195 Fvc(909)$61-3117 �`�9�� � BUILDING PERMTT APPLICATIUN FIRMLY ,. ,. , ,..,, � JOBSITE �^,��� �� DATEICATION �r �1,,,(J ! NUMB R � #/C o A�DRESS �1C.✓ �^ c� ISSUE TYPE OCC APN L T TRI}C�T, DATE CONS7. GROUP °C OWNER GL� O p ADDRESS ZONING SETBACKS � CITY e d a ZIP�'�STEL. REART � ❑ APPLICANT �• SIDElSIDE STREET RW ❑ � CONTRACTOR G_ SIDE G Q ADORESS � CI1Y r ZIP TEL. PROPOSED USE oARCWENG! � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY Z1P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION f1� OOWNER-BUILDER DEGLARATION SFR/ADD/REM p I HEREBY AFFIRM UNDER PENAITY CF PERJURV THAT I AM EXEMPT FROM THE CON7RACTORS LI� � Garage/Carport W CENSELAWFOR7HEFOlIOWINGREA50N(SEC.7o31.5BUSINESSANDPROFES310N5CODE:ANYCITYOR � CWMfYWHICHREOUIRESAPEAMITTOCONSTRUCT,ALTEA.IMGR01lE,OEMOLISH,ORREPAIRANY5TRUC� W Patio/Deck TUHE.PqqH TO ITS ISSUANCE.AL50 REW�RES 7HE APPLICANT FOR SUCH PERMIT TO FILE A 51GNE0 W .� STATENENT THAT HE OR SHE IS LICENSEO PURSl1ANT 70 iHE PROVI510N5 OF THE CONTRACTORS LI- � CENSE lAW�CHAPTER 9(COMMENCINO WITH SECTION�000)DF DIVISION 3 OF TH[6USINESS AND PRO- V" POOUS�3 FESSIONS�E�ORiHATHEORSHEISEXEMP7THEREFN�PAAND7HEBA5I5FORTHEALLEGEDEXEMP- (�J TION,ANVVIOUTIONOFSECTION7031.SBYANYMFLICANTFORAPERMIiSUBJECTSTHEAPPLICANiTO � Re-Roof � AqNL PEN�LTV OF NOT MOqE THAN FIVE HUNDRED DOLIARS(5500).�: � ❑I.ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPEN5ATION, C� COf!1RIBfCIdI ' WILL W THE WORK,AND THE STRUCTURE IS NOT INTENDE�OR OFFEFlED FOR SALE(SEC.7044,BUSI- J NESS N9D PROFESSIONS CODE:TV1E CONTRACTORS LICENSE LAW DOES P10T APPLY?O qN OWNER OF � PROPERTYMMOBURASORIMPROVESTHEREON,ANDWHODOESSUCNWORKHIMSELFORHERSELFpq m _ � THqOU(iHHISORNEPONMEMPLOVEES,GNOVI�EDTNATSUCHIMPROVEMEMSARENd71NTENDEOOR QOFFEREDFORSQEIF,HOWEVERTIIEBUILDM�ORIMPiiOVEMENTISSOLDWI7HINONEVEAPOFCOMPLE- Z TION,THE 05VNER-BUILDEH WILL HAYE 7HE B��RDEN OF PROVING THAT ME OR SHE DID NOT BUILD OR � IMPROVE fOR THE PURPOSE OF SA6E). ❑I.AS OWNEA OF TME PRPPERTY,AM EXCLUSIVELY CONTRACTINf WITH L:GENSE�CONTRACTORS � TO CONSTRUCT THE PRQIECT(SEC.7014,BU51NFS5 ANQ PROFF_SSIONS CODF:THE CONTRACTOFS LI- ValUfltiOn _ADJ,AREA W CENSEIAWDOESNOTAPPLYTOANONRJEROFAPROPEPTVWtiOBUILDSDRIMPM?VESTHEREON,AND � WFqCONTRACTSFORSUCHVROJECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTO7HECANTMF QUANTITY DESCRIPTION FEE X TORS UCEN9E UW.). g �_� J ❑I AM EXEMPT UNDEfl SEC. __ B.8 P.C.FOR THIS REASON � 3 � � LL" OATE oWNER __.� _ f' Z ^ w Q LICENSED CONTRACTORS DECLARATIpN � � w I HEREBYAFFIRM UNDER PENPLTY OF PERJURY THAT I AM LICENSED UNDER PRO'✓ISIONS OF CHAFTER � � p� 9(COMMENCING WR'H SECTION 7a00)OF OIV�SION 3 0F THE BUSINESS ANO PROFESSIONS COD� z X MY LIGENSE IS IN GULI FORCE AN�EFFECT.. m LLI ` 0 LICENSE CLASS UC.NO. .,,�_ � � V DATE __ CONTRACTpR a W _ _ � WORKEPS'C6MPENSATION GECLARATION —� d � I HEREBY AFFIRM UNDER PENALTY OF PEPJURV ONE OFTHE FOLLOWING DECLqRATIONS � (d� Z Q Q> >I HAVE AND WtLL MAINTAIN A CERTIFICATE OF CANSENTTD SELF-INSURE FOR YYORKERS' S � COMPE ATION,AS PROY�DED BY SECTION 3"�OOOF THE LABOR CODE,FOR TF1E PERFORMANCE �U OF RIC FOti WHICM THIS PERMIT IS ISSUEU. � � �I HAYE ANO N7LL MAINTAIN WORKERS'COMPENSA7!ON INSURANCE,AS RE�UIRED BY SECTIDN � 37CO OF THE LA90R CO�E,FOR THE PEqF RMMIGE OF THE WPRK FOR WHICH THIS 7ERMIT'�.5 ISSI,'ED.MY WORKER�COMPENSATION IN RANC[CAflRIER ANO POUCV CONSTRUCTION J e: PLAN REVIEW �.. CARRIER - — , Z PaICYNUMBEa +��1�L�_- ELECTRIC __ _ __ 4 0 (fl#SSECI1bNNE�N01'BECCFAPLEfEDOFiHEPERAA'1'ASSbRONEM:MIREDD�IlARS(S10G)ORLESS). PLUMBING _ 1�1 � Z ICERTIFYTHATINTHEPERFORMANCEOFTHFWOpKfORWHICH7HISPEFM�TI51S5UEq� MECHANICAL _ � (,�'J SHN.L N07 EMPLOY FWY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TOTHE � WORKEPS'COIAPENSATIONLAWSOFCALIFOqNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJEGTTOTHEWORKERS'CAMPENS PROVISIONSOFSECTION37o00FTHELABOR � ; (��y `� y�\ CODE,ISHALLFOIlTHWITFICOMPLVWI 7H ROVISIONS. �SSUANCE -tl'0}�, "��Q,p�, � '-� O py 1 v DAT'6:,��`�p IAPPL�CANT: ` _ .�._'_'_ SMIP ,�y ,+-��at7�y�p . J ENERGV P/C �-/��?+���Vi JF./zY#'4� WARNINO:FAILUHE TO SECURE WQRKERS'CAMPENSATION COVERAGE IS UNLAWFUI,AND SH4LL BE �7 7�7�F,�1 �@ q�y��er}tgp LL SU&IECTANEMPLOYEflTOCflIMINALPENALTIESANOCNILFINESUPTOONEMUNOqEDTHOU3AND ENERGVPERMIT � "��+�111��7�1'+Y��%'9�r"P`=� Y �OLLqRS(t100,000).IN AbDITION TO THE COST OF COMPENSATION,DAMAGES AS PPOVIDED FOR IN � SECTION 37�8 OF YHE LABOR CODE.1�'TEREST,ANDATTOftNEY'S FEES. RETENTION FEE: — � CONSTRUCTION LENDINGAGENCY PRE-ALT FEE _ O � IHEREBVAFFIRMUNOERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCY _ FOR THE PERFORMANCE OF THE WORI(FOR WHICH THIS PER611T IS ISSUEO(SEC.3081,CIV C). Z W � LENpEfi'S NAME _-- F— LENDER'SADDRESS --- W I CERTIFY TMAT I Y.AVE REA�THIS APPLICATION ANO STATE THAT THE ABOVE INFORMATqN IS CARNECT. TOTAL FEES � I AGPEE TO COMPLY W1TH ALL CIiY AND COUNTV ORDINANCES AND STATE LAWS REIATING TO BUILOING CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFT ISCWNNTOENTERUPONTHE Z ABOVE-MENfIONEOPROPERTYFORINSPECTlO PUftPO5E5. 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