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HomeMy WebLinkAbout17281 CITY OF DIAMOND BAR C'�'^/ -----�``' -� DEPARTMENT OF C�MMUNITY 8c DEVELOPMENT SERVICES ✓' I 21825 E.Copley Drive (909)860-3195 Faac(909)861-31 l7 PRESS �"'-�%��� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ��� Q , j � �� APPLICATION ��,�j,;� PERMIT � P/C O� �� o ADDRESS_ �J � DATE ��� �� NUMBER #______�� °D APN LOT TRACT I�U 6�'O �SSUE TYPE OCC -�--}-- DATE CONST. GROUP p OWNER :I �`'tvtf "- ADD SS 2�{7 S. ' � S o( �--1/l ZONING SETBACKS oCITY�t�ct r ct ZIP �I17l�S"T��oZ9 FRONT RW I l o APPLICANT ,��'�S AT'Cr]Lt�'S�L�TEL. S�� S DE/SI�E STREET RW ❑ Z ¢ CONTRACTOR �UJ 2 ��'' SIDE � o ADDRESS � "� pROPOSED USE IP ' �� �OIC+ I�o� D o crrr 1a`�z ,I ziP t? G TEL. 9�G^ F�Q� � r � o ARCH/E G/ z DESIGNER w NO.DWEL. NO. NO. � ADDRESS UNITS I STORIES I BEDROOMS = C1TY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADOlREM O p 1 HEPEBY AFFIRM UNDER PENALTV OF PERJURYTHAT I AM E%EMPT FROM THE CONTRACTORS LI- G8f8Je/Cefp01l W CENSELAWFORTHEFOLLOWINGREASON(SEC.70315BUSINESSAN�PROFESSIONSCOOE:ANVCITVOR (n U CqUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,iMPROVE,�EMOLISH,ORREPAIRANYSTRUC� W Patio/Deck ��" Z TURE,PRIOR TO ITS ISSUANCE.AL50 RE�IJIRES THE APPLICANT FOR Sl1CH PERMIT TO FILE A SIGNED w STATEMENT THAT HE OR SHE IS LICENSED PUFSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- W � CENSE LAW rCHAPTEfi 9(COMMENCING WITH SECTION 7000)OF OIVISION 3 OF THE 6USINE55 ANO PRO� V' POOVSpd FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDE%EMP- � � TION.ANYVIDLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMRSUBJECTSTNEAPPLICANfTO Z R2-ROOf A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED OOLIARS(E50o).�: ❑1,AS OWN ER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, p � Commercial Z WILL DO THE WORK,AN�THE STLIUCTURE IS NOT INTEN�ED OR OFFEREO FOR SALE(SEC.7od4,BU51- J � NE3S AND PROFESS�ONS CODE:THE CONTRACTORS UCENSE LAW DOES NOT APP��i0 AN OYINER OF = PROPERTY WHO BUILOS OR IMPFOVES THEFEON,AND YMO DOES SUCH WORK HIMSELF OR HEqSELF OR � THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHA7SUCHIMPRWEMENTSARENOTI�YTENDEDOR m QOFFEREDFORSALE.IFHOWEVER.711EBUILOINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z T�ON,THE OWNER-BUILDER WILL HAVE THE BUP�EN OF PROVING TMAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE). rJ I,AS OWNER OF THE PPOPERN,AM EXCLl1SNELV CON'RACTING WITH LICENSED CONTRACTORS � TO CANSTRUCT THE PROJECT(SEC.7044,BUSINESS ANO PflOFE5510NS CODE:THE CONTMCTORS U- VBIUeIlOf1 ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOVJNEROFAPROPERTYWF709UILPSORIMPFOVESTHEREON.ANJ - � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)UCENSEDPURSUANTTOTHECONTFAC- QUANTITY DESCRIPTION FEE Y TORSLiCENSELAW.). � ❑1 AM E%EMPT UNDER SEC, B.8 P.C.FOR iHiS REASON Q � U � � DATE OWNER U W a LICENSED CONTRACTORS DECLARATION W � IHEREBVAFFIRMUNDERPENALTYOFPERJURYTHATIAhALICENSEDUN�ERPROVISION50FCHAPTER � [L 9(COMMENCINGWITHSECTION7000)OFDIVISION30FTHE8USINESSAN�PROFESSIONSCOOE,AND Z X MY LICENSE IS IN FULL FORCEAND EFFEC7 0 LICENSE CLASS ^ LIC.NO. �,��� � V DATE j �+�-_ Q/ CONTRACTOR r . a W � WORKERS'COMPENSATION DECLARATION -� ¢ � I HEREBY AFFIRM VNDER PENALTY OF PERJURY ONE OF7HE FOLLOWING DECL0.RATIONS: Z Q � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSEIF-INSUREFOPWORKERS' _ CAMPENSA710N,AS PROVIDE�BY SECTION 37vo OF iHE LABOR CODE,FOR THE PERFORMANGE C� � OF THE WORK FOR WHICH THIS PERMIT IS ISSU'c0. � � W ,�.I HAYEAN�WILL MAINTAIN WORKEflS'COMPEYSATIDN INSURANCE,AS REQUIREO BV SECTION ,� d� Q 3�OOOFTHELA90RCODE,FORTHEPERFORMANCEOFTHEW�RKFORWHICHTHISPERMITIS ISSUED.MY WOR R5 COMPENS�A.,T/p N INSURANCE/C��a RIER ANO POL'"CYNUMBEf1 ARE: CONSTRUCTION � CARRIER �'�r"��""�- `-'A' PLAN REVIEW � � T`— � z POLICYNUMBER �� � � � ELECTRIC Q ..,.._._�.,....,..._....,._.:.,_._...._.�m...,�x_,.»..._,. � (RIISSECTIONNEmNOTBECC#APLEfEDOFTIiEPEW�Ui1SP7RONENUMRED00llPJiS(5100)ORIES$) PLUM8ING ,��_`5-"j'^"' ^� W ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL �L�rc^�~~/��� ,�� - �""`�/� Z � SHALL NOT EMPLOY ANY PERSON IN ANY MANNEft 50 AS TO BECOME Sl18JECT TO THE � WORKERS'COMPENSATIONLAWSOFCAIIFORNIA,AN�AGREETHATIFISHOULDBECOAeE INSPECTIONFEE SUBJECTTO THE VlOPKEflS'COMPENSATION PftOVI510NS OF SECTION 31000FTHE LABOR I � CODE,:SHPLIFORTHWITNCOMPLYWITNTHOSEPROVISIONS. ISSUANCE � s�-f .�� T-�, � DATE: APPLICANT: SMIP 9 v _W,,,i ENEAGY P/C ���` ' J WAfiNING:FAILURE TO SECUPE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALLBE --�-,-------.-.---;;�_---�,�.--�;-+� �y SUBJEGTANEMPLOYEHTOCHIMINALPEM1ALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � � A~ OOLLARS(S100.000),IN hDDITION TO THE COST OF COMPENSATION,DAMAGES AS PRONOED FOR IN `l � SECTION 3]oe OF THE LA30R CODE,INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: �a V� OCONSTRUCTIpN LENDINGAGENCY PRE-ALT FEE: � IHEREB�AFFIqMUNDERPENALTYOFPER:URVTHATTHEREISACONSTRUCTIONLEN0INGAGENCY _ FOR THE PERFORMANCE OFTHE WORK FOR WN�CHTHIS PERMITIS ISSUED(SEC.309�,CIV.C.�. Z � W � LENDEWSNAME f^ LENDER'SADDRESS � TOTAL FEES � � I CERTIFV TMAT I F'AVE REAO THIS APPLICATION ANO STATE THAT THE ABOVE INFORMATION IS CORREC7 � W IAGREETOCOMPLYWITHALLCITYANDCOl1NTVORDINANCESAND57ATEIAWSRELATINGT06UIL�ING � CONSTRUCTION,ANO NEREBY AU7HOR2E R[PRESENTATNES OF THIS COVNTV TO ENTER UPON THE � ABOVE�M�N7ION�OPEflTY FD INSPECTION PURPOSES. COMMENTS �, Q l�� � � m PERMITT AME INT ¢ v�o2 G3 � � � SIGNATU I E ��' = RECPT.N0. PAiD BY VALIDATION ~ WHITE—Departmen[Copy,YELLOW—Finance Copy.PINK—Assessor Copy.GOLDENROD—Fi�e Copy,GREEN—AppllcanYs Copy .: �.-.�..u�:.� .. .._�,.,.,.,�-,�,.,.....;.�T....;..rc:.,k„ .. ,�':;� �::rr:�;ar� ,.553;.:, ��;ras,M1��Y^>4Yr.e..w,.ft?'taru.i�:.�nep:':iv,'�4. . 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