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HomeMy WebLinkAbout10933 ; I�,t`'.} f / i � j �' `i --�`"ti-- CITY OF DIAMOND BAR � ( � COMMUNITY DEVELOPNIEN'1'DEYARI'MENT :_� �. ' 21660 E.Copley Drive Suite 190 �RESS ' (909)R60-3195 Fax(909)861-3117 ��'� BUILDING PERMIT APPLICATION FIRMLY o� JOBSITE G, / G/ /// � N4PPLIGATION �� NUMBER t ld � C :' ADDRESS ! �v _ DATE i m ISSUE TYPE OCC APN LO� TflA DATE CONST. GROUP ; p OWNER � �; � ZONING SETBACKS � ADDRES G / I Z CITY lZ� TEL. 3�� FRONT RW ❑ APPLICANT TEL. REAR O � o SIDE/SIDE STREET — RW J � CONTRACTOR .�-=� SIDE G � CI'fY S � ZIP��D TEL. � PROPOSED USE � "�� " O � w� ARCH/ENG/ � Z DESIGNER NO.DWEL. NO. NO. a ADDRESS � UNITS STORIES BEDROOMS � � CITY ZIP TEL. g N DESCRIPTION SQ.F7: FACTOR PSF ADJ.AREANALUATION 1 -�- OWNER-BCILDER DECLARATION SFR/ADD/REM O p. I H'eREBY AFFIRM UN�ER PENALTY OF PERJUflY THAT I AM E%EMP7 FaD.L1 TME cONTRACTORs ll- Gafage/Carport - - LLJ- CENSCLIWFOFITHEFOLLOWINGREASON(SEC.7031.58USINESSAN�PAOFESSIONSCA'JE:ANYCITYOR (n U- COUNTYYiIHICHRECUIRESAPERMiTTOCONSTRUCT,ALTEfi.IMPROVE,DEMOLISH,ORflEPAIRANYSTRUC- W patio/Deck Z' TUAE,PRIOR TO Ii5 ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILt R SIGNEU W- STATEMENT THAT H'c OR SHE IS LICSNSE�PURSUAM TO THE PROViSIONS OF THE CONTRAC70RS LL - � - �� CENSE LAW(CHAPTER 9(CAMMENqNG WITH SECTION 7000)OF DIVISION30f THC BUSMESS AND PRO- - � PooUSpa O'. FESSIONSCADE)OflTHATHEOR5HE15EXEMPTTHEHEI-HOM/4�OTHEBASISFOftTHEALIEGEDEXEMP- -- � U; 770N.ANYVIOIATIONOFSECTION7G31.58YANVAPPLICANTFORAPEf7MIT5lJBJrCTSTHEAPPLICANTTO Re-Roaf �_ A GIVIL PENALTY OF NOT MOfiE THAN fIVE HUNDRED DOLLARS($500).): � �_, ❑I,ASOWN`tROFTHEPROPEflTY.ORMYEMPLpYEESWITHWAGESASTHEiRSOLECOMPENSATION, �� Commercfal - Z; WILI DO THE tVORK,AND THE STflUCTURE-IS NOT INTENDED OR OFFERE�FOR SALE(SEC.704a:BUSI- - J �._ NE55 AND PROFESSIONS CODE:THE CONTRACTOFlS LICLNS[LAw DOES NO7 APPLY TO!�Y OWNEA OF- :� PROPERTYWNOBUILOSORIMPROVESTHEREOM1,ANOWHODGESSUGHWORKHIMSELFORHERSELFOR- m �: THROUGHHISORHEROWNEMPLOYEES,PROVI�EDTHATSUCHIMPROVEMENT5ARENOTINTENDEOOfi -IL_- OFFERE�FORSALE.IF,HOYJEVER,PrieBU0.DMGORIMPHOVEN.ENTISSOLOWITHiNONEYEAfiOFCOMP�E- -0'- TION,THE OVdNEfl-dUIL�ER WILL HAVE THE BURDEN OF PROVINQ THAT HE OR SHE 01�NOT BU:ID OR - -� IMVRDVEFORTHEPUPPOSEOFSALE�. - - � - _' ❑I,ASOWNEROFTH[PROI'EflTY,AMEXCLU51VElYCONTRACTiNGWRHLICENSEDCONTRACTOflS - W, .(,r_� TO CAN5TflUCT THE PR0.IEGT(SEC.704a,BUSINESS AND PROFESSIONS CODE:THE CONTRACTOfl'a LI- VBIUef10f1 ADJ.AREA IL--- -CENSELAWOOESNOTAPPLVTOANOWNEROFAPflOPEPNW40BUILD50FIMPflOVESTHEFEON,AND: _--� WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(5)LICENSEOPURSUANTTOTHEfANiRAC- - - -QUANTITY DESCRIPTION FEE ~-� TORSLICENSELAW.). Y- J �-' ❑I M1 EXEMPT UhDER SEC. - B.&PG FORTHIS REASON� Q 0= U 'S`- � �' ��:' DATE OWNER ~ _ - ' Zi W �`- LICENSED CON"�RACTORS DECLARATION _ . � ; Q _� . .�__ IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHATIAMLICEVSEDUttOERPROVI510N50FCHAPTEft j�- — -d-. 9(Co.V.IAENCINGWITHSECTIqN7o00JOFDiVI5iON30F7HEBUSINESSANDPPOFESS!ONSCODE,lYD- Z .X= MY LICENSE IS IN fULI FORCEAND[(f[CT. ._ m �/ � -��' UCENSE CLASS � LIG NO. � ��\ / � -� -_U:;_ DATE � CONTRACTO � -_ a . W: -o�� WORKERS'COMPENSATION DECLARATION Q -�- . . .. _ . . . U . � ��- 1 HEflEBYAFFIflM UNDER PENALTY OF PERJURV ONE OF THE FOLLOWING�ECLAFATIONS: - . � Z Q. :��-. IHAYEANDWILLMAINTAINACERTIfiCATCOFCONSENTTOSELFJNSUREFOHWORKERS' $ - - -Z� COMPENSATION.ASPflOVI�EDBYSECTION37000FIHELABOftCODE,FO�THEPEFFONMANGE- U _� ¢=. OFTH[YlOflK FOR WHICH THIS PEFMIT IS iSSl1ED. _ � � W I HAVE AND WILL AIAINiAM WORKERS'COMPENSATION INSIIRAhCE,AS RE�NRED BY SECTION /� � ' j�y�� I -Q` 3�aoOFiHELFBOFGODE,FORTHEPEflFORMANCEOFTHEWORRFOHWHICHTHISPERMITIS - ���� (,J(.� i ��' ISSUED.MYW K fi' TI04!N P RIERAND LICYNUMBERARE CONSTRUCTION � j�` caaRie PLAN REVIEW _� --�� POiICYNUMBER ` � - ELECTRIC . Z; Q� � :�� (IHISSEC710NNEmNOTBEOJMPLEf'eOaFTHEPEFI�ATISFOPQ4EHUNDREDDOU.ARS�b100)ORLFSS) PLUMBING . � 'W� MECHANICAL -z: i CERTIF1'THAT INTHE PEf1FORMANCE OF THE WONK FO�WHICH THIS PERMIT IS ISSUED,1 <(3' SHALLNOTEMPLOYMIYPEPSONIhANYMANNER50A5TOeECOMESUAJFCTTOTHE INSPECTIONFEE '(A' WOflKERS'COM?ENSATIONLAWSOFCAL�FORNIA.AN9AGflEETHATIFiSHOL'L�BECOME � �j _F- SU&IECTTO7HEYJORKERS'COMPENSATIOYPROVIS!ONSOFSECTION37uVOFTHELABOfl � ✓7 i -.�; . CODE.I SHALL FOFTHWITH CAMPLV WITH THOSE PROVIS'ONS- �SSUANCE �/ • r'j '� �O3 SMIP U -p- -.DATE: APPLICAN7. ` �-�� WARYING:FAI�URE TO SECUPE YJOFKERS'COMPENSATION COVEflAGE IS UNL4WFUL,ANO SHFLL BE ENERGY P/C /� /y y { :��. -SUBJECTANEMPLOYEflTOCflIMINALPEkALTIESAN�CIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPEiiMIT �F9i�a n��! � DOLLAflS�5100.000�,IN AO�ITION TO TME COST OF GOMPENSATION,DAMAGES AS PFOVIDEO FOR IN ��� �. -�-J� SECTION37080FTNELABORCOUE,INTEREST.ANOATTOR�EY'SFEES. - RETENTIONFEE: �': �t�;. CONSTRUCTION LENDWG AGENCY PRE-ALT FEE: .:0; ;�'_ I HEREBV AfFIRM UN�Eft PENALTY OF PERJURY THATiHeRE IS ACONSTRUCTION LEN�ING AGENCV ___ �4. FORTHE PER:ORMANCE OF THE Y�ORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30B7.CIV.C.). , . W.. - -_'��- LENDER'SNAME ��� .>1==: �ENDEfl'SADDRE55 � '�°- ICEftTIFYTHATIHAVEREADTHISAPPLICF110NAND5TATETHATTHEABOVEINFOFMATIONISCORPECT. 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