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HomeMy WebLinkAbout16097 (23) ' / ����� . ,_ „�� CITY OF DIAMOND BAR ���� p/G( DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive 5wte l90 '��';.���.+W BiTII.DING PE (RMIT APPLICATION FIRE LY __ � J08SITE , f p APPLICATION PERMIT �P/C o ADDRESS ��"l � � �1.�'��C�� �� DATE NUMBER # $ ISSUE TYPE C APN LOT TRACT DATE � • C�NST. GROUP °� OWNER (3�`1 �`p ADDHESS �� Y ZONING SETBACKS � CITY Cif(I'lL�i'1 � f ZIP TE b,? FRONT RW ❑ APPUCANT � 'TEL " � �� FEAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTOR � Q C: if" SIDE ❑ g ApDR S ` %'L CITY f'r�lG' . ZIP `��'�✓ L . � -�I f+ PROPOSED USE � ARCHlENG/ � DESIGNER — NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION OOWNER•BUILDER DECLAHATION SFFVADD/REM p I HEREBV AFFlRM UNDER PENAL7Y OF PERJURY TNAT I AM EXEMPT FROM THE CONTRACTORS LI� � Garage/Carport W CENSELAWFORTNEFOLLOY/INGREASON(SEC.7o31.58U51NE55ANOPROFE5510N5CO�E:ANYCITYOF ZCOUNTVNMICHREWIRES�PEflMtTTOCONSTRUCT,ALTER,IM7ROVE,DEIAOLISH,ORREPAIRANVS7RUC� W pa�jOlDeCk W TUHE,PRIOR TO IT$ISSUMICE,AL50 REW IFES iHE APPLICANT FOH SUCH PERMIT TO flLE A SIONE� W .� STATEAIENT THl.T HE OR SHE IS UCENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS Li� c CENSE LAW(CIIAPTEq 9(COMMENCMO WITH SECTION 70Do)OF�IVISION 3 OF THE BUSINESSAN�PRO� V' POOUS(J8 4 FE39�ONSCODE)ORTWUHEORSHEISE7(FMPTTHEREFROMAN�THEBASISFORTHEALLEGE�EXEMP• (�} V TpN.ANYVIOLATIONOFSECTION)031.6BVANYAPPUCANTFORAPERMITSU&IECTSTNEAPPLICANTTO Z Re-Roof � ACIVIL PENALTV OF NOT MORE THAN FI"JE HUNORE�DOLLAflS(5500).); � ❑I,ASONMEROFTHE�ROPEi1TV.ORMYEMPLOVEES'MTHWAGESASTHEIHSOLECOMPENSATIpN, � Cammercial - WILL DO THE WORK,ANO THE STAUCTURE IS NOT INTE40E0 OH OFFERED FOP SALE(SEG.704q,BU51� J NESS N7�PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW�OES NOT APPLV TO AN OWNEii OF � PflOPERTYWF108U�DSORIMPROYES7HEREON,ANDNMODQE551JCHWORKHIMSELFORHERSELFOH = � THRIXIOHHISORHEH9WNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEAAENTSARENDTIMEN�E�OR m � ,OFFEREDFORSALEIF,IpWEYER���LDIN00RIMPROVEMENTISSOIDWITHiNONEYEAROFCAMPLE ' Z TION,THE OWNER�OUILpER WILL HAVE THE BURDEN�F PROVINa THAT HE OR SNE�ID NOT BUIID OA � IMPROYEFORTHEPURPOSEOFSALE�. W ❑I,ASOWNEROF'fHEPROPEFfTY,M7EXCWSIVELYCAN7RACiINGWITHLICEN5E0:ANTRACTORS � TO CONSTRUCT THE PRQIECT�SEC.704t,BUSINESS AND PROFESSiONS CDDE:THE VbNTRACTORS LI� VdIU8fI0n ADJ.AREA W CENSELAWOOE3NOTMPL7TOANOWNEROFAPFSOPERTYWHOBUILOSORINPROVESTh1EREON.ANO � WFfOCONTMCTSFOPSUCNPRO.IECTSWITHACONTRACTOR(S�UCENSE�7URSUANTTDTHECON`:RAC- pUANTITY DESCRIPTION FEE Y 70RS UCENSE UWJ. � J � O f AM E7(EMPT UNDER S�C. B.6 P.C.FOR THIS REASON U _ '� — � LL DATE OYMER,_ V Z W qLICENSEO CONTRACTpRS DECIARATION W Q I HfF�BYAFFIRM UNDER PENALTY OG PERJURV THNT I A!A LICENSED UNDER PROVI510N5 OF CHAPTEP � � � � 9(COMMENCINO WI'M SECTKKJ 7o00j OF DIVISION 9 OF THE BUSINESS AND PROFESSIONS CADF,AND Z X MY LICENSE IS IN FULL FOPCE AND EFFECT, m LLI C� r' � UGENSE CAASS�C-�� LIC.NO._ ���� �✓ � � �], � U ppTE_ _ CONTRACTOAL►�'��C'� ��r a W � WORKERS'COMPENSATION OECLARATION ¢ � I HEREBYAFFIHM UNDER PENALTV OF PERJUflY ONE OF 7HF FOLLOWiNG DECLAM710NS: � � Z Q � ,IMAVEANDWILIMAINTAINACERTIFIGATEDFCONSENTTOSEIF-MSUREFORWORKERS' S COMPBNSATlOM,AS PROVIDEO BV SECTION 370o OF THE UBOR CODE,FORTHF.PERFOPMANCF �U OF THE WOFK FOfl'MiICH THIS PERMIT IS ISSUF.D. � � W ,IHAVEANOWILLMAINTAMWOflKERS'CAM?ENSATION7NSURANCE.ASRE�UIREDBYSEC710N Q 37000F THE iA80A CODE,Ftlp TME PERFOHMANCE Of THE WORK f0�9 WHICH THIS PERMIT IS d ISSUED.MYWO�ERS'COMpPENSATI.' URANC�E/�n RPoERANDPOLICYNUM6ERARE: CONSTRUCTION gCANRIEP ' �Vl- q�u��W�`� PLAN P.EVIEW � POLICY NUMBER O�G`°v�.�,}SL_��- — ELECTRIC Q o (iFiuSECiqNNE�N�TBE�tMLEfEDOF1}EPERMTISF�RONEHIN�IEDDOLLAfi�(Ef00)ORLESS4 PLUMRING x W MECHANICA� Z ICERTIFYTHATINTHEPERFORMANCEOFTHEYYORKFORNMICN7HI5PERMITIS:SSUF.D,I (� SHA�LNOTEMP.CVANYPERSONINANVMANNERSOASTUBECOMESUBJECTTOTHE � d�;:` � WORKENS'COMPENSATIONIA'NSOFGALI�ORIVIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE � SU&IECTTO THE WbHKEPS'C0IAPENSATION PROVISIONS OF SECTION 9]OOOLTL?E LA90R ''�� �- S CODE.�SMALLFOF7iMWITNCOMPIYWITN/T�NPSEPROVI510N5. ( �SSUANCE �_"�""`'�' �/� 1 6 p DATE: APPLICANT. J=IS1'k�.���.V��^�� SMIP ��'�gi'+g g+' �g�'�t��^..�sp�����'Y��$�� �'�g � J WARNING FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUI,AND SMALL 6E ENERGY P/C �l«�Af,�&A`VA-1 +"Ti�+.�'°-'+����'Y LL, SU&IECTAN FMP�OYERTO CflIMINAL PENALTIES ANO CIV�L FMES UP TOONE HUNDREOTHOUSAND ENERGY PERMIT DOLURS(5700.0001.IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTpN37080F7FiELABORCODE,INTEflEST,ANDATTORNENSFEES. RETENTIONFEE: � � CONSTRUCTION LENDING AGENCY PRE-AlT FEE: O � I HEREBV AFFIFM UNDER PENALTY OF PERJURY THATTHERE IS A CONSTRUCTION LENDMG AGENCV FORTHE PERWRMANCEOFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED(SEC.3097,CIV.C.�. Z W � LENOER'SNAME ___ _. 1— LENDER'SADDRESS ------. � ICERTIFYTHAYIHAVEREADTHISAPPLICATIONANOSTATE7HATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES Y � I AGFiEE TO COMPLY WITH ALL CIN ANO COUNTY ORDINANCES AND STATE tAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF THIS COUNTV TO EMER UPON THE Z VE�MENTIONEDPflOPERTYFORIN PECTIONPURPOSES. COMMENTS s � � � m PEflMI ENAI E(PPINT) ` ' d � � SIGNA UREO ERMI EE � DATE = RECPT.NO. 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