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HomeMy WebLinkAbout12279 (13) ' CITY OF DIAMOND BAR ---��� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Ihive 5uite 190 � (909)860-3195 Fvc(909)861-3117 PRESS ��'�'�+� BUII.DING PERMIT APPLICATION ' ,��� FIRMLY ,- _ . — p� JOBSITE /�J��� ,�f},�r.�?��� �', DATE CATION � NUMBER ��� #/C ADDRESS E 1 ,�< <.,�� (/ � ISSUE TYPE OCC APN LOT T 7RACT DATE CONST. GROUP p OWNER " ADDRESS ZONING SETBACKS �W CITY ZIP I TEL. REART RW O APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR ` SIDE L� d ADDRESS � Ci7Y iP TEL. PROPOSED USE pARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNEF-BUILDER_DECLARATION SFR/ADD/REM O [� 1 HEREBY AFFlRM UNOER PEN/LLTY OF PEHJUHY THAT 1 AM EXEMPT FRDM THE CONTRACTOPS LI- � Garage/CarpoR W CENSELIWFORTHEFOLLOWINGHEASON(SEC.703t.58U51NES5h4DPROFE5510M15WDE:ANYCIiVOq C7 COUNTYWHIpiNEIX11HE5APERMR7000NSTAUCT.ALTER.IMPROVE.DEMOLISH,OflflEPAIRANYSTRUC- [J,� PdfiO/�BGk WIURE,PRIOR 70 ITS ISSUANCE.ALSO RC-0UIflES THE APPLICANT FOR SUCH PERMIT TO FILE R SIGNED � W STA7EMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIDNS OF THE COMRACTOflS LI- - � CEN5ELAW(CHAPTERe(COMMENCINGWITHSECTION9000)OFOIVISION30FTHEBUSINESSANDPqO- - u' POOUS� FESSIONS CODE)OR THATHE OR SHE IS EXEMPT THEREfROM AND THE BASIS FOF THEALLEGED b(EMP- U TION.pNVVIOIATIONOFSECTiON7a37.5BYANYqPPLICANTFOflAPEflMITSl1BJECTSTHEAPPI�CANTTO - - z Re-Roof r ACMLPENALiYOFNOTMORETHANFNEHUNDREDDOLLARS(5500).): ❑I,ASOWNEqOG7HEPROPERN,ORMVEMPLOYEESWIhIWAGE5A5THEIRSOLECOMPEN5A71oN. - 0 COmmefCial ' -. g� NfiLL 00 THE K'UHK.MID THE STftUCNRE IS NOT INTENDED OR OFFEflEO FOR SALE(SEC.7046,BU51- J NESSANDPROFESSIONSCODE:7HECONTNACTORSLICENSELAWOOESNOTAPPLYTO ANOWNEROF - � PROPEHTYNM1iO&11LO50R16iPPOYESTHEREON.ANDYMO00E55UCHWORKHiMSELfORMERSEIFOR � -- � THPAUtliHI30RHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAqENOTINTENDEDOR . m . W OFFEREDFORSALE.IF,HOWEVERTMEBUILDMGOR�MPROVEMENiISSOLOWfTHINONEYEAPOFCOMPLE- �_ .�TION.IHE OWNEH-BURDER VYILL W1VE TME OUflDEN GF PqOYlNO THAT HE OR SHE 01�NOT BUIfD Ofl .� IMPROVEFORTHEPURPOSEOFSALE). W ❑I,ASOWNEflOFTHEPROPERI�:AMEXCIUSiVELYCONTflACTINGWITMUCENSE�CONTR0.CTORS - � TO CONSTRUCTTHE PRQIECT(SEC.10�I,BUSINESS AND Pi10FESSfONS CODE:THE CONTPACTORS ll- - V0IUfl1fOf1 ADJ.AREA CEN4E LAW DDES NOTAPPLY TO AN OWNER OF A PROPER7Y WHO BULLDS Ofl IMPROVES TMEREON,ANO �. -NRpCONTMCT5FOR5VCHPqOJECTSWITHACONiMCTOR(S)IiCENSEDPUflSUANTTOTHECONTftAG QUANTITY DESCRIPTION FEE - � TOfiSt10ENSELAW.). ❑I AM IXEMPT UN�ER SEC. 6.&P.G FOR THIS REASON Q � U � LL'� OATE OK'NEfl U W - � UCENSEDCONTRACTORSDECIARATION -� - iNEPEBYAFFIfiMUNOERPENALTVOFPERIURVTiAT1AMLICENSEDt1N[)EHPfiOVISION50FCHAPTER � --�- 9(COMMENpNOWffhISECTKKJ�aao�OFDIV15�ON30FTHEBU5INESSANDPROFE5SI0NSCODE,ANP Z X MY{lCENSE IS W FULL FORCEAND EFFECT. m Ill .A � �. UCENSE C S LIC.NO. . J �`j DATE �' "' CONTR4CTOR a - W � WORKERS'COMPENSATION DECLARATION � U � IHEHEBVpFfIRMUNDERPENALNOFPEflJURYONEOFTHEWLLOWINGOECLARATIONS: uj Z � ,. � _IMAYEANOWILLMAINTAINACERfIFlCATEOFCANSENTTOSELF-INSl1REFOflWORKERS' 2 . COMPENSATION.ASPROVIDEDBYSECTION37000FTHEUBORCODE,FORTHEPERWRMFNCE - U Q /�p F7HEN'OFKFORWHICd1THI5PERMITI5155UED. � W �J J[__i MAVE ANO WILL MAi�'fAIN WORKEAS'COMPENSATION INSURANCE.AS REDUIRED BV SEC710N B 37000F7HELABORCODE,fORTNEPERWHMANCEOFTHEWOPKFORWHICHTHI5PER411T15 0 ISSUED.MV WQP.K �S'COMP SA INSURANCE RR� AND PO NUMBERARE: CONSTFlUCTION � CARRIER "� � _ PLAN REVIEW � ��cYNUMBEfl_ - � " _ ` ELECTRIC __. .__ __ ���\(�/ Q (IFUSSECTIONNE�NOTBECaAR.ETmOF1NEPEM4TISWHONEFNNDREDDOLlARS(5700)ORLESSJ. - BING .�_�� ) • �'-. - - W � MECHANICAL � Z � 1 CEFTIFY THAT IN THE PERFORMANGE OF THE WDRK FOH WHIGH THIS PERMIT IS ISSUED,I — . -- - �-(�f-- SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESU&IECTTOTHE � INSPECTIONFEE - " - N WORKERS'COMPENSATION LAWS OF CALIFOqNIA,AND AGREE THAT IF I SHOULD BEGOME � Stl&IECTTOTHEWOflKERS'COMPENSATtONPflOVISION50F5ECTION370oOFiNELABOR ISSUANCE � L � � CA�E,ISHALLFOFiTMWiTHCAMPLYWITHTHOS Pq VI IONS. - p DATE:_Z_`:L��APPLICANT:----'-�� . SMIH _ ._-- w � v ENERGY P/C � J WARN�NG FAI�URE TO SECUPE WOflKEflS'CAMPENSATION CAVEPAGE IS UNIAWFUL,ANO SHPLL BE �y SU&IECTANEMPIAVEHTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ppLLAHS IS1oo,oDD),IN AODITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � � SECTION37080FTHELABORCODE.INTEREST.ANDATTORNEY'SFEES. - RETENTIONF�"E:3� _ t? �.. Q CONSTRUCTION LENDING AGENCY PHE-ALT FEE�-'� � �'� O � IHEREBVAFFlflMUNDERPENPLTVOFPERJ�NVTHATTNEAEISACONSTRUCTIONLENDINGAGENCY FOR THE PERFOFiMANCE OF THE WORN FOR WHICHTHIS PERMIT IS ISSUED(SEC.3os�,CIV.C.). � W _ _' � LENDERSNAME F— LENOER'S:1DOflE55 W ICEflTIFYTHATiHAVEREADTHISAPPLICATIONANDSTqTETHATTHEABOVEINFORMATIONISCDRRECi TOTAL FEES -Q IqGREETOCOIAPLYWITHALICITYAN�COUNTYOH0INANCESANDSTATELAW5flEU71NGTOBUILDING . .+�a.`a�� CONSTRUCTION.ANDNEF7EBYAUTHOFIZEHEPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE �J � ABOVE-MENTIONED PROpE0.TY f-0R INSPECTION PURPOSES. 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