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Home My WebLink About12840 (13) , .-_,�, �� l .. > _ �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES�-" � �� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 , F�RMLY ��'AM. BUILDING PERMIT APPLICATION � JOBSITE �f �, /� � � ADDRESS s�� ''�' ��'�� ~�� T1�� DATEICATI�� '�� NUMBER " 1 � #/C � � ISSUE IYPE OCC APN LOT TRACT DATE CONST. GROUP � OWNER 7. ' O � ADDRESS , � ^'' ZONING SETBACKS oCITY L��1) L��dfC./ ZIP��y TEL. � FRONT RW LJ _ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREEf RW [J � CONTRACTOR �� > . °� �. SIDE n_____._ � ADDRESS f�3�� 'J�^y��.J(;�t.�,�_„� p �T PROPOSED USE CITY ,f�� ZIP7� TEL. .'� o ARCWENG/ DESIGNER �i - NO.DWEL. NO. NO. n_ ADDRESS � UNITS STORIES BEDROOMS � CITY __ ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBV AFFIRM UNDEfl PENA�TY OF PEHJURY THAT I AM E%EMPT FFOM THE CONTRACTORS LI� � � � Garage/Caryort W CB�ISELAWFORTHEFOLLOWINGREASON(SEC.7037.SBUSINESSANDPROFCSSIONSCADE:ANYCITYOR U COUN7VNMICNREWIRESAPERMITTOCANSTRUCT,ALTER,IMPROVE,DEIAOLISH,OR{iEPAIRANYSTFUC- {J,J pafi0/DBCk W TUqE,PFIOH TO 1T8 ISSUANCE,ALSO HE�UIRES THE APPLICANT FOR 3UCH PERMIT TO FILE A SIGNE� � STATEMENT THAT HE OR SHE IS UCENSE�PtJRSUPNT TD THE PflOYI510N5 OF TME CONTflACTORS LI� �' CENSE LAW�CHAPTEfl 0(COMMENCIN�WITH SECTION 7000)OF�IVISION 3 OF THE 6USINE5SAN�PRO� LL' POOUSPB � FESSIONSCOD�OflTHATHEDflSHE15EXEMPTTHEREFROMANDTHEBASISFORTHEAlLEOEDE%EMP� '� (� V TION.pNYVqLAT10NOF5ECTI0N7031.59YANYAPPLICANTFORRPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACMLPENAL7YOFNOTMORETHANFNEHUNDREDDOLLARS(5500)J: ,� ❑I,ASOWNEROFTIEPROPEi1TY,OflMYEMPLOYEESWITHWAG[SASTHEIflSOLECOMPENSA7lON, � COlI1fI10fCidl ' � 1'ALL DO THE WORK AND TNE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7044,BU51� J N NES£AND PROfESSION3 CODE:IHE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF ? PROPERTY NM1W BUILAS OR IMPROVES TNEREON.AND WHO DOES SUCH WORK HIMSEIF OR NEPSELF OR �CL� TMFqUCiFIHI50RHEROWNEMPLOYEES.PROVIDEDTHATSUCNIMPROVEMENTSAREir'OTINTENDEDOR � � ��, ,OFFERm�OR3ALEIF,HOWEVEFLiHEBIJILDINGOFiIMPROVEMENTIS50LDWITHINONEVEAROFCAMPLE� 'TION,THE ONMER-BUILDEfl WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DIO NOT BUILD OR � IMPpOYEWRTNEPURPO5EOF5ALE). W_ ❑I,ASONMEROFTHEPROPERT:AMEXCWSNELYCOARRACTINGWITHIICENSEDCOMRACTOqS � TO CONSTRUCT THE DROlECT(SEC.7041,BUSINESS ANU PROFESSIONS COOE:THE CONTflACTORS ll- V8IU8110f1 _,.._.,,_,ADJ.AREA CENBELAWDOE9NOTAPPLYTOANOWNEROFAPROPERTYVYH09UILDSOFIMPROVESTHEFEON,MI� -- ----- �'., WNOCONTPoICTSFORSUCHPflOJECT5WI7HACONTRACTOR(5)L!GENSEDPURSUAN(TOTIIECONTflAG QUANTITY DESCRIPTION FEE � TOpSt10ENSEUW.�. �,��: ❑IAM EXEMPT UNPEF SEC._____ __B.8 P.C.FORTHIS REASON � l6. � 'v`a , DATE OWNER U � Z W �,�,. LICENSED CONTRACTORS DECLARATION W � �� -- ---- -- , t. pp I HERF.flY AfFIRM UNOER Pf.N4l.TV OF PERJURV THAT I AA1 LICENSF.D UA;DER PROVISIONS OF CHAPTER J n:'✓}n.� <.- 0 .,,.. qq :(y? Y(ODMMENCINf3W1TF75ECTIONtoWjOFDIVI310N90FTHEBUSINE93ANDPROFES310N9CODE,AYD �. Z , C.� 4�fJL �i4j��ri� �- A 1 � � MY tICENSE IS M FULL PORCE AND EFPECL � �' �y rJ� / I` � "7 al-��"�i ��"�./.,��' Cs •}' `0;� LICENSE CLASS i"'"""�� LIC.NO. �G^+E� 7� ; � g- ,.. '~•. DATE �� _,� CONTRACTO /Kr . .��J��v •� ;W i - %�`?'� / ' /U�r I�/ .o`,j� �:� WORKERS'COMPENSATIO ECLAH.ATION �,•' � � .�,, �I HEREBV AFFIqM uNOEii OENALTY OF PEFiIURY ONEOF THE FOLLOWING DECLARATIONS�,� z Q 0 __IHAVEANDWILLMAINTAINACEfi�IFlCATEOFCONSENTTOSELF-0NSUREFORWOFK[RS' _ �� COAIPENSATION,ASPROVIDEDBYSECTION970aOFTHELAWRCOUE,FORTNEPERFORMANCF. 'U __ _ 0' OF 7HE WOHK FOR WHIGi TMIS PF.RMIT IS ISSUED. � �W` �. I HAVE PND WILL MAINTAIN WOFKER9'COMPENSATIOY INSUflANCE,AS REQUIRED BY SECTION �.Q� 370o OP7HE LABOR COOE,FOR THE PERFORMANCE OF THE WOBK FOR WHICH THIS PERMIT IS �0;. ISSUED.MY WOP.KEAS'COMPENSATION INSUMNCE CARRIER ANU POLICV NUMBEH ARE: CONSTHUCTION _. „ _'_._..,...._.._....._—'... � ��.� CRRRiER ��"� : . PLANREVIEW i 0 POLICYNUMBER LGP(C.O��.�`� fS'� '�I / —.__-.._...____—_.._.._.._— . I ,. -�� ' ELECTR Z ......-- � ( 4 � W� (iFiISSCCiIONNE�NOTBEC�00.�LEfFDOFTHEPEPh4TlSF0(iONEHINOFiE000U.ARS1�100)ORlES5). PLU BING.� ___._ _-_—_'��_.._.J.. - I �.•�� I 'Z� I CERTIFV THAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL � .(j SHPi1NOTEMPLOYANYPER50NINANYM/NNERSOASTODECAMESUBJF:CLTOTHE ;(p YfbRNERS'COA7PENSATION LAWS OF CALIFORNIA,Ml�AGREE THAT IF I SHOULD�ECOME INSPECTION FEE ___.__ � �� SU0.IECTTOiHEWORKERS'C�MPENSATI PqOVI510NSOFSECTI 37000FTHELABOR -T -� CODE,I S ALL F THW�yITy COMPLV WI OSE PPOVIS�ON.� Y � ISSUANCE ,._.______.__. _.,.�__-~� `p oaTE: ^�.:'�� /J qrPLiCANT _. /•�� ..�i' Y --�- SMIP ------�.�- ------- J WAPNING:FAILUFE TO SECUR[WOFKER' MPENSATION COVERAGE IS UNLAWFUL.AN�SH�LLOE ENERGY P/C � _...."' __-- —'..._....'_ '� SUBJECTANEMPLOYERTOCRIMINAIPENALTIESANDCIVILFINESUP700NEHUNDREDTHOUSAND ENERGVPERMIT '+ � DOLLARS(E700,000),IN ADDITION TO THE COST OF COMPENSATION,UAMRGLS AS PHOVIUED fOR IN T -- '��J SECTION97080FTHELABORCODE.INTEREST,ANDATTORNEY'SfFES. RETENTIONFEE: �1JTNT} R ARn. ,.� �""____-- ,�� . CONSTRUCTION LENDING AGENCY PHE-ALT FEE: ._._________ 0.` r�.� O . ..�. t HEREBV AFFIRM UNOER PENALTV DP PERJURY THAT THERE IS ACONS7RUCTION LENDING AG[NCY FOR THE PERFOqMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEU(SEC.3091,CIV.C.�. Z W —'—_ �' LENDER'SNAME� "'__"'_ '__"'". .--. ,._ —_' _ .1-' LENDER'S ADDR�55''� "_ —.—._...'_"'_' � TaTAL FEES ' � � 1 CERTIFV THAT�I HAVE READ THI5 APPLIGA710N ANU STATE THAT�TNE ABOYE INFOFlMATION IS CORRECT. w IAGREETOCOMPIYWITHALLCITVANbCOL/NTYORDINANCESANDSTATELAWSRFLATINCTOBUII.DING � CONSTflUCT10N,AND HEHE6V AUT4fORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON iHE ZABOVE�MENTKKJED PROPERTY FOF INSPECTION PUHPOSES. I COMMENTS � .3'� Y«I'Es'� .��.L�� (,}D � — m .PEHM EE NAME(PRII � � , _ � �- �� _ , __ " NATU E OF PERAIITTEE TE � RECPT.NO. 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