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HomeMy WebLinkAbout11241 (5) i i ' ---�```E--� C1TY OF DIAMOND BAR ' � � � COMMUNITY DEVELOP1bIENT DEPARTMEDI"I' i , � -��",,, 21660 L.Copley DriveSuite 190 P��SS ' (909)A60-3195 Fax(909)8613117 � ��'4�'. BUILDINGPERMITAPPLICATION FIRMLY o DDRIESS !� /� /�+' If'��� �� DATEICATION..��� � �( NUMB R � #/C ��� o ISSUE TYPE OCC `r APN LOT TRACT DATE CONST. GROUP � OWNER � 0 " ADDRESS @ , ZONING SETBACKS z CITY = + ZIP� TEL. �d" FRONT RW C ZAPPLICANT ��`3 TEL. REAR ❑ � SIDEISIDE STREET RW ❑ m CONTRACTOR � � SIDE � ❑ � ¢ ADDRESS � � � � 4 � CITY �"C:� P` ZIP � fEL. �/ L PROPOSED USE ; o ARCH/ENG/ W OESI6NER NO.DWEL. NO. NO. a A�DRESS UNiTS STORIES BEDROOMS = CITY ZIP TEL. � DESCRIPTION SQ.Ft FACTOR PSF ADJ.AREANALUATION cn • .� OWNER-BCILDERDECLARATION � SFR/A�D;REM O 7 p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAf I AM EXEMPT F(iOM THE CONTflACTOflS LI- GHf29B/CHIPOfI q LLI CENSELAWFOflTHEFOLLOWMGREASC.4(SEC.]031.SBUSINESSAN�PROFE5510•JSCO�E:ANYCITVOR (�___ � U COL'MYWHICHREQUIRESAPERAIITTOCONSTRUCT,ALT'cR,IMPFlOV[,DCMOLISH,OflflEPAIflANYSTRUC- W patio/Deck -Z- TURE PR:OR TO ITc�SSUA4CE,ALSO RE�UIRES THe APPIIGANI FOH SUGH PERMIT TO FILE A SIGNED W W STATENENT THAT HE OR SHE IS LICENSF�PURSt1ANT TO THe PROVISIONS OF THE CONTRACTORS LI- d � CEN3E LAW(CHAPTER 9(CAMMENCING WITII SECTiO4]000)OF�IVISIOY 30F THE BUSINESS AND PRO� -rt POOVSpa � FESSIONSCOD`e)ORTHATHEORSHE!SEXEMPTTHEPEFPOMAND�HEBRSISFORTHEALLEGEOEXEMP- � 0� TION.ANYVIOJ�TIONOFSECTIOh7o3159YANVAPPI.ICANTFORAPERkITSUBJECTSTHEAPPLICANTTO Z Re-Roof U- ACIVIL PENALTY OF NOT MOflE THAN FIVE HUNDREO DO:LARS(5500).): . � ❑I,ASO'JJNEROFTHE?ROPERTY,OHAAYEh'�?LOYEESWITHYIAGESASTHEIRSOLECOMPENSATIOV, � - . WILL DO THE WOFK,AN�THE STRUCTUqE IS NOT INTENDED OR OFFEflED FOR SALE�SEC.7044,BUSI- � COrtImEfCi21 Z NESS AND PROFESSIONS CODC:THE CO4TRACrORS LICENSE LAW DOES NOT APPLYTO AN OWNER oF �- PROPEflTYWHOBUILDSORIMPAOVESTHEREON,ANDWHODOE55L'CHYJORKHIMSELFORHERSELFOR � [C- THROUGH NIS OP HEF 014'4 EN,PLOVEES,PROV:DED THpTSUCH IUPaOYEMENTS ARE NO7 W?ENDEDOR . m . �w-- OFFEHEDFORSALEIF,HOWEVEP,iiiEeUILDiNGORIMPROVEMEtJTISSCtAWITHINOYEY'rAftbFCOA7PLe- ��- TiON,THE OY/NER-BUILDER V/ILL HAVE THE BUR�EN OF PROViNG THAT HE OR SHE DID NOT OUIIA OR Z--- !pAPROVEFOATHEPURPOSEOFSALE). _ ❑I,ASOVlNEROFTHEPROPERTY,AMEXCLUSNELYCONTHACTMGVlITHLACEkSEDCONTRAC70R5 .WW-•� TO GONSTHUCT THE PflOJECT(SEC.]OaS,BUSINESS AND PROFESSIONS CODG THE CONTPACiORS LI- . �CEKSELAW�OESNOTAPPLYTOANO`NNEROFAPROPERTYWY.OBUIL�SOHIMPFOVESTHEREON,AND Vdlu3ti0fi ADJ.AREA -_: WHOCONTflACTSFORSUCHPROJECTSWiTHACANTRACTOR(S)LICENSEDPUFSUANTTOTHECONTfUC- QUANTITY DESCRIPTION FEE -~ TORSLIGENSELAW.). I Y .�- -�� ❑I AM EXE�IPT UNDER SEC. 9_8 P.C_FOR THIS REASON ' � - r �. f � � � DATE OY/NER _ U Z-. W i�` LICENSED CONTRACTORS DECLARATION -_ W - ¢ -�- IHEREBYAFFlPMUNDERPENALNOFPEFiJURYTHATIAMIiCEYSEDUNDERPROVISIONSOFCFiAPTER ''�I ��- �% �j .� i :.�-: n(COMMFNCMG WITH S'eCTIDN 7C00)OF DIVISION 30F THE BUSiNESS AND PROFE5510YS GOOE,AnO , z iB . . :X-- M'/LICENSE IS 14 FULI FORCE ANO EFFECT. � - m . . - W-;. ���. IICENSE CLASS�p L� UC.NO. � -_ � - �-V._ DATE �PL� "yl� CONTRAC70R _ W- �r� .� WORKERS'COMPENSATIONDECLARATION � Q � U -��� 1HEREBYAFFIRMUNDERPENALTYOFPERJURYO�EOFTH[FOIIOWINC�eCLARATIONS: �: Z � ��� IHpVGANDWILLMAINTA!NACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ . . . - - �Z• COMPENSATION,AS PiiOVNEO f5Y SECTION 3]�o OFiHE LABOR GODE,FOfl TME PEFFOft41ANCE U � - ¢� �BF'THE WORK FOR WHICH THIS PEAMIT IS ISSUED. � _ _ 0" � W� I HAV'c ANO WILLMAINTAIN WOFKFRS'COMPENSATICN INSURA�CE AS REQUIRED BY SECTION - d-- 370o OF THE LABOH CODE.FOR THE PEHFOFt�dANCE OFTHE WORK FOR WHiCH THIS PERMIT IS -�+-- ISSUEO.!AYWORKERSCOMPENSATIONINSURA CECARRIERANDPOLICYNUMOERARE: CONSTRUCTION J: .j� cnanieq . �y�°� y � �[-�/-�ry- - PLAN REVIEW - �0�- vouCYNUMBER a P f�.+'T" • [—�„�`�Q��— ELECTRIC : ¢ y -��__ (IHSSECTqNNE�NDT8E00MPLEfEDOFTHEPEMNTISWRONEHUNJF1tD00lAAH5(51oo)ORLE55} PLUMBING � � C - - �Z� ICERTIF1'THATINTHEPERFON67ANCEOF?HEWOFKFORWHIGHTHISPERMITISISSUED,I MECHANICAL - -�- --- -. ::�� SHALLNOTEMPLOYANYPERSONINANVMANNERSOAST08ECOMESU&IECTTOTHE : ._... _—_ - ... -. . .(� - WORKERS'C6MPENSATIONLAWSOFCA!IFORNIA,ANDAi,ftEETHAT�F�ISHOULDBECO!l.E � --INSPEGTIONFEE -=- - - - - -�--�--- � SUBJECTTOTHEWORKERS'WMPENSATIONPftOVI510N50F5ECTIQ�37oUOFTHEIAeOfl -�—� � �� I - � = CADE,I SHALLFORTHWITH COMPLY WITH THOSE PftOVI510N SUANCE !°/�f8 f A ���_ � SMIP `p: DATE:-s� APPLICANT . . `w-- ENEFGV P/C =-J�- WARYINGFAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANOSHALLBE .� :-LL_; SUBJECT/�EMPLOYERiOCRIMiNALPENALTIESANDCNILFINESUPTOONEHl1NDiiF�THDIISAND ENERGYPERMIT - OOLLAFS(5100,000),IN ADDITION TO THE C0.ST OF COMPENSATqN.DAMAG[5 AS PROVIOE�FOfl IY "J"` SECTION 37oB OF THE LABOR CO�E,INTEflEST,ANOATTORNEY'S FEES. RETENTION FEE: �: -�pw_,'" CONSTAUCTION LEND W G AGENCY PRE-ALT FEE: O'- �'- 1 HEREBYAFFIqM UNDER PENALTY OF PERJURYTHATTHERE IS AGONSTftUCTION LENDING AGENCY -�-- FOR7HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUEO(SEC.3097,CIV.C.). - Z� W. --__ I.EY�ER'S NAME - �:: ��1—� LENOER'SAODRE55 �-��� ICEPTIFYTHF�IHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEMFORMATIOVISCORRECT. TOT/YLFEES ��� �� -W' 1 AGREE TO CQUPI Y WITH ALLCITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING ��' CONSTRUCTION,ANDH[f7C8YAUTHORIZEREPRESENTAT!VESOFTHISCOU�TYTO'cNTERUPONiHE �.�r.� �j���.y�.�q /� 3� '�-- A00VE�MENTIONED PROPEflTY FOF INSPEGTION P RPOSES. �/{a�J/ }Yln�I7/,L+�/� /•��/� �� z� COMMENTS �-•---i� a n.+ �rr[�+ o= ,�-�1 '_ - -- - .�.m PERMITTEENAM T) � . Q. UJ:. � .��-:� SIGNATUREOFPE MITTEE DATE ..j .__: FECPT.N0. 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