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HomeMy WebLinkAbout16369 (20) ' , CITY OF DIAMOND BAR °a� --—�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ` � , 2]660 E.Copley Drive Suite 190 I (909)860-3195 Pae(909)861-3117 PRESS �'''°�''�' BUII.DING PERMIT APPLICATION FIRMLY JOBSITE , PERMIT P/C r ""' i APPLICATION u o ADDRESS � � � ��+ � �" DATE 1' � ��� NUMBER �_�� # ( � ISSUE TYPE OCC � � APN—�{-- LDT TRQCT DATE CONST. GROUP p OWNER W1l `_t;� �sca�c � a ADDRESS —'� =---_ ZONING SETBACKS � � CITY ZIP `" TEL. ��^' ��c-� FRONT RW ❑ � APP�ICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ i � CONTRAC70R �. �ii 4� ' SIDE ❑ �, i+ � � CI1Y E\`--c..��� ZIP��TEL�' ��I G I� PROPOSED USE �"L ltv� �'� �c� oARCH/ENG/ � DESIGNER ADDRESS NO.DWEL NO. NO. � CITY ZIP TEL UNITS__�_ STORIES _�BEDROOMS � cn- DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER�ECLARATION . SFR/ADD/REM � O I NEREBY AFFIFq1 UNDEfl PENPLTY OF PE(L1URY THAT I AM EXEMPT FROM THE CAMRACTORS li- G2f8J0/CdfPOI'I � -W�� CBISELAWFORTHEFOLLAWINGREASON(SEC_7a91.58USiNESSANDPROFESSIONSCODE:ANYCITYOR � (n U COUN{yWH�qiREW11flE3APEflMITTOCONSTHUCT,ALTERIMPpOVE,DEMOLISH,ORREPAIRANYSTRUG �. W Pyi10/DBCk W... NRE,PRpR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED �., W STATEAIENT THAT ME OR SHE IS�ICENSED PURSUANT TO 7ME PROVISIONS OF THE CONTRACTORS ll- - �- CENSELAW�CHAPTER9(CO\IMENCWaN7THSECTION)OOOjOFDIVIS10N30FTHEeUSINESSANDPflO- �� POOVSPH ���� FESSIONSCODt�OHTHA7HEOR5ME15EXEMPTTHEqEFROMANDiHEBASISFORTHEALIEGEDEXEMP- , (� V: TION.ANYVIOLATIONOFSECTION7Q37.6BVANYAP7LICANTfORAPERMI7SU&IECTSiHEAPPLICANTTO Z Re-Roof - �:: A GIVIL pENALTY OF NOT MORE THRN FIVE HUNDRED�OLlARS(t50D)J: OI,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEE6WITHWAG�SASTHEIRSOLECAMPENSAT�ON, - � COrt1rtIBfCi81 - ' .��- WILL 00 THE WOfl14 iW D THE STRIJCTURE IS NOT INTENOED OR OI-FEPm F�R SPLE(SEC.70M.BUSI- -. J �;_ NESS AND PROFESSIONS WDE:THE CONTRACTOFS LICENSE LAW�OES NOT APPIY TO AN OWNEfl OF '. ? - � _ PR�EN7VWMIOBUII.�SOHIMPROVE57HEREON.ANDWHOOOESSUCHWORKHIMSEIFOHHERSELFOR -.2'- TMi10U(1HHISORHEqOWNEMPLOVEES,PROYIDEOTHATSUCHIMPROVEMENTSARENOTINTENOE00fl 'm _� OhFEiimFOR5ALEiF,HOWEVER7NE9llIL01NGORIMPPOVEMENTISSOL�WITHINONEVEAROFCOMPLE- z.- TION,SHE OWNER-BUILDER WILL HME TNE OURDEN OF PROVING THAT HE Ofl SHE OID NOT BUILA Oq - - - �.-, IMPppVEFORTHEPURVOSEOF3ALEJ. - � . W ❑I,ASOWNEROFTHEPROPEHTY,AME%CLUSIVELVCONTflACT1NGWIl71LICENSEDCOMRACTOqS �- — — �. -TO CONSTRUCTTHE PRQIECT{SEC.70t4,BUSINESS AND PROFESSIONS CODE:h!E CONiRpCTORS LI- VelUeti011 ADJ.AREA I.U� CEN9EUWDOESNOTMPLYTOANOWNEflOPAPROPERTYYJ1t08UlIDSOflIMPROYESTMEflEON,AND �- WFIOCONTRACTSWqSUCHVROJECTSWITHACONTqACTOfl(S)LICENSEDPURSUANTTOTNECOMRAG QUANTIN DESCRIPTION FEE � TORSLICENSELAW.). . - �. J ,O_ ❑IANEXFhiPTUttDERSEC. B.&P.C.FORTHISREASON ' Q � U � � :� . DATE_ _OWNEfl______ __.. . U _ � Z W � -�- UCENSEDCONTRACTORSDECIARATiUN -• W � _�. Ih1ERE8YAFFIRMUNOERPENN.TYOFPEFUURYTHNTIAF7UC'cN5`cDUNuERPFOVISIONSOFCHAPTER - � � p�- s(COMMENdNGWIMSECT10tJ7000�OFDIV151ON30FTHE9USINESSANDPROFES51045CO0E.AND � Z � ]C AIY LICENSE IS M FULL FppHCE EFFECT.- r� �f -�- LICENSE CIAS@• `� �� LIC.NO. � 1�` /____ _ :.� j F_. \ _iQ�L�--�-- � J V; onrE �"�--��'�•� coNrrucTOA v c4� uy n. � w. -��, WORKERS'COMPENSATION DECL4RATION -� --i � ¢ -�, 1 k1�0.E8YAFFIRMi UN�EP PENALTV OF PEKNRY ONE OF THE WLIOWING DECLAflATIONS: -_ Z � -__�:_ _IHAYEANDWIlLMA1MR�NACERTIFlCATEOFCON5Et1TTOSElFl4^uUREFORWORKERS' � ¢ 2 COhIPENSATbN,AS 7ROVIDED BV SEC7fOY 3�OOOF THF�ARpR CODE,FOR THE Pefi��'-ORMANCE - U Q �YYORK FOft WHICii THIS PER41T IS ISSUEO. -. � B: --W--- �I HAVEAND WILLAWNTA�N WORKEAS'COMPEN5ATION INSURANCE,AS REQUIRED 6V SECTION /� JJJ��� -d� 37000FTHEV50RCO�E.FOflTHEPERFORMANCEOFTHEWORiCWflWHiCHTHISPERMlT1S � / � ,:¢a i55UEQ.MYW.O�5'COM NSATi�U��Rfl1EqANOPOLICYNUMBERARE CONSTRUCTION � ! J � >_ cnAaien - PLAN REVIEW •0=' poucv r�uMs[a `�� ELECTRIC z Q _p_, (tFp55E(.'TKMNE�NO78EWAfPLETEDQF7Fu'PER4YTt5FQi(MiEMNARmDCLlHRS(51oD)ORLESS� PLUMBING :-.Z-_ 1 CERTIFYTHAT INTHE PERFOHMANCE OFTHE WOHK FOR WHICH THIS PEFMIT IS ISSUED.I MECHANICAL -.� -�j- � -SHFLLNOTEMFIOYANYPERSIXiiNANYMANNEFiSOAS?08ECOMESUBJECTTOTHE _ -:��- - -WORKERS'COMFENSATIONLAWSOFCALIFOqNIA,ANDAGREETHATIFISHOLILDBECOME - � INSPECTIONFEE ._ :�-_ SUBJECTTOTNEWOflKEflS'COMPENSATIONPflOVISIONSOFSECTIDN37ooOFTHEIABOR _ � ;� CO�E,ISHALLFORTHWITHCOMPLYWI T}iOSEPROVIS N5. �SSUANCE 0 �� f � _ � -� -p-- DATE: ��__C � APPLICANT:� SMIP __ : 4 -�� WARNING FAIIURETO SECURE WORKtFS'COMPENSpTION COVEflAGE IS UN /FUL,AND SHALL BE ENERGY P/C ��"` - ' -'�LL� -SU&JECTANEMPLOYERTOC{iIMINALPENAITIESANDCIVILFMESUPTOONEH�NDREOTHOUSAN� ENERGYPERMIT OOLLAflS(f100.000).IN HDDRION TO THE COSTOF GOMPENSATION,DAMAGES AS PHOVIDED FOR IN � -J' SECTION37080FT1ELABORCODE,INTEflEST,ANDATfORNEY'SFEES. RETENTIONFEE: i� � � --d-: CDNSTRUCTION LENDING AGENCY PRE-ALT F6E: O' -�. 1 HEREBY AFFIflM UNDEH PENALTY OF PERJURY THATTHERE IS ACONSTHUCTION LENDING AQENCY " FOR THE PERFORWWCE OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.3097,CIV.C.j. - W — _�__ LENOER'SNAME_ --F-- LENOER'SADDRESS y� ,/� ���:�-' ICERTIFYTHA7IHAYEREP�THISAPPLICATIONANDSTATETiATTFiEABOVEMFORMqTIONISGOPPECL TOTAL FEES I � ),aJ� w i AGREE TO fAMPLY W1TH ALL CITV AND COUNTY OROINANCES ANO STATE LAWS RELATING TO BUILDING i /J' �.� CONSTRUCTION.ANDMEREB7AUTMOFiIZEREPPESENTATIVE50FTHI5COUNTYTOENTEftUPONTHE �T � AOOVE�MENTIONE�PFlOPLRTV FOR INSPECTION PURPOSES. COMMENTS � \� �v. � ' o -- _ ��lL J�(:�G Z-� - — m PEflMITTEE E(PRINI) `' - �- f� �-��h Y�_� - . - � .SIONATURE OF PEFiMITTEE UATE ��� - ' _ - RECPL NO��J �/� PAID BY r VAUDATION � ~ WNITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENRO�File Copy,GNEEN-ApplicanYs Copy � <.. ._-. -. _.: i� �....... " .� �-. 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