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HomeMy WebLinkAbout10064 CITY OF DIAMOND BAR COMMUNITY DEVELOpIo9ENT DEPARTMENT �,.,� 2]660 E.Copley Drive Suite 190 PRESS (909)860-3195 F:ix(909)861�3117 "'"°� BUILDING PERMITAPPLICATION FIRMLY ;g. 0 D RIESS.V I / ,v` �� L L�"�r DATEICATION � -�''q NU 0 R #/C c� ' ISSUF TYPE OCC APN LOT TRACT � DATE_ CONST. GROUP o ApDRE -y- , LU� � D L)1: �Q� ZONING SETBACK5 z CITY ' / ZIP TEL.� FRONT RW Cl_ o APPLICANT _ 7 � REAR ❑__! Z SIDE/SIDE STREET RW f7 � CONTRACTOR� .o nS'- �C7� SIDE _ L]_ � ADDR SS 5:5`S W • ��l P_n- . � `7 - �_- � CITY�ff'N /'L tdG-7�.�- ZIP � 7EL.� - �� PROPOSED USE_ �.GL w ARCWENG/ — z DESIGNER - - ND.DWEL. NO. NO. � ADDRESS UNITS STORIE5 BE�ROOMS � CITY ZIP.---- 7FL.-----,— — — � D�SCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cn � OWNER-BI:ILDER DECLARATION SFPJADD/FEM I HEREBY AFFIHM UN�F.F PENALTY OF PERJUqY THAT I AM EXEMPT FHOM THE CONTiiAGTOR3 LI• ' G3fd90/C3fpOR W CENSELAWFORTHEFOLLOWINGREASON(SEC.703158USMESSAN�PROfE5510Y5CODEANYCITYOR (f' .�_ U WUNTYWHICHqEWIRESAPEAMITTOCON3TRUG7,AL:Efi.IMPqOVE,OEMOLISH.OPflEPAIRANVSTqUC- W pailolDeck L TUqE,VflIOR TO ITS ISSUANCE,ALSO HE(]UIflE5 THE APPLICANT FOR SLIGM VENMIT TO FIIE A 51GNEfJ � STATEAIENT THAT HE OR SHE IS LICENSEO PURSUANT TO 7HE PNOV151(]NS OG THE COVTRPCTORS ll. 'w � CENSE LAW�CHAVTER 9�COMMENCIN(i WITH SECTION 7000)O(�IVISION 3 OF TNE BUSINESS ANO PRD� u" p00�.(la FESSIONSCODE�OflTHATHEORSHEISEI(EMPTTNEREFROMANOTHF.BASISFORTHEALIEOE�EXEMP- � � TION.ANVVIOLATION�FSECTION7031.56VANYAPPLICANTFORAP[RMITSUBJECT5THFqppLICANTTO Z Re-Raaf F A CIVIL PENALTV OF NOT MOHE THAN FIVE HUNOfiED OOLVIRS(5500].�: Q ❑I,ASOWNEROFTHEPROPERTV,ORA/VEMPLOYEESWITNWAGESASTHEIRSOLC:GOMPENSATIOY, ❑ COmfYle[Cldl z WILL DO THE WORK,AND THE STqUCTURE IS NOi INfENDED OR OFFERED FOR SPLE(SEC.7046,BUSI- ,J •�' NE55 ANO PROFESSIONS fAOG:THE CONTFACTORS LICENSE LAW DOGS NOT APPLV TO AN OWNER OF � PROPERTY Vh10 BUILDS Oq IMPROVES THFREOk,AN�WHO OOES SUCH N'ORK HIMSEIFOR HEFSELF OR �' THROUGHHISORHEqOWNEMPIOYEE6,PROVIDEDTHATSUCHIMVROVEMENTSARENOTINTENDEDOH m Q� OFFERED�Oq5P1E.IF,HOWEVER7HEBUR�INGORIMPROVEMENTIS50Li7WITHINONEVFJflOFC0AIVLE- __ � TION,THE OWNER�BUILDER WILL HAYE 7HE BUIi�EN OF PROVING 7HAT HE OR SHE DID NOT BUII.D OR � IMPqOYEFOqTHEPURPOSEOFSALE�. i.l l,AS OWNER OF THE PflOPERfY,AM EXCLUSNEL.Y CONiRACTING WITH LICENSF:D CONTRACTOHS � � TO CONSTpUCT THE PROJECT(SEC.70a1,BUSIME55 AND PROFESSIONS CODE�.THE CONTRACTOpS LI- V8Il18IlOfi _,_.. _______.,_AOJ.AflEA_ : W GENSELAWDDESNOTAPPLYTOANO'MIFROFAPflOPERTVWHOBUItDSORIMPROVESTHEflFON,AND � WHOCONiRRCTSFORSlJCY1PROJECTSWITHACONTRACTOH(5)LICENS[DPURSIIANTT07HECONTRAC- QUANTITY DESCRIPTION J�;x, FEE Y TOI15 LICENSF UW.). � ❑I AM E%EMPT UNOER SEC._._ _B.4 V,C.FOR THIS REASON , Q � ' � � '_.___—"_—_"_" '—' "_' '�'— :�. � ��D � u" DATE___. � _. OWNER___' '__"�__'__.... V � W � LICENSED CONTRACTORS DECLARATION � �� � � IHEREBYpFFIflMUNDERPENALriOFPEfiJUfiY7NA71AMLICENSEDUNDER?ROVI31045C.FCHAPTEFl � ey �/h ` ✓J� (i 9(WMMENCINGWITHSECTION]OOO�OFDIVISION30PTHEBUSINESSANDPROFES510@SCODE.AND Z �•/ �X AIYLIGENSEISINFULLFOHCEANDEFFEGT / `�' (�"j] m �. � IiCENS� SS "— LIC.NO._T 03(��/�___ ��. � :�-�.=��------- �.��-- , _ r U � DATF CONTflACTOH a W ./l./j�� •. �i� WORNERS COMPENSA710N DECI_ARATION �'t�� = U +f � 1 NEREBYAFFIIM LINDER PENALTY OF PERJURV ONE OF THF FOLIAWMG DECLARATIONS: /�' CA Q '��VCJ1C. .- `�' Y '' . � _.___.!HAVE ANU WILI A7A;NT•A1N A CERTIFICATE OF CONSENiTO SELFINSURE FOR WOqKERS' S ;'� �U L� � — CAMPENSATION,AS PROVIDED BY SECTION 3�00 OF THE LABOH CODE,FON THE PEAFORUP,NCE W OF TH[WOflK FOfl WMICH THIS PERMIT IS ISSUED. � � W ,I NAVE ANO WILL MAIY�AIN WORKERS'COMPFYSAT:ON INSUPhNCE,AS NEQUIREO BY SLGTIIXJ Q9]OOOFTHELABORCODE.FORTHEGERi'ORMPNCEOFTHEWOAKfOflWHICHTHISPEFMITIS ISSUED.MY WO K 5'CO/MPF.�NSAT�IO,N INS.U-fRAN.,C,E C�ARRIEFAND PUUCY NUMBERARc: CONSTRUCTION .__ ._,._ __ � ('� q �v C�''�,�'.l�/� ���--� FIAN PEVIEW _ �j_„[� : ] CARRIEfl _ �Ar�• ...�-7J �—" _ "_' < �C...f � VOIICY NUMBER_.._���.��.L�-d�_—— E�ECi� _"'_ — �5� ¢ Q (iHiSSEf,ipNNE�NOTREC�Mf'LETFDOFTFEPERFRiASf�`FiONEMN�EDDOIfl�A$(S10�ORLESSA PLUMBING _ .- �... ZICERTIfYTHATINTHE7EPFORlAANCEOFTNEWORKFOflWH�CHTHISPERMITI515S�E0.l MECHANICAL __ G� � '�'��� (J � SHALLNOTEAIPLOVANYGERSONINANYMANNERSOASTOBECOIdLSUHJECTTOTHE � ' (n WORKERS'CqMPENSATIONI.AW50FCALIFOqNIA,AN�AGREF7HATIGI5NOt1LDUECOME �NSPEGTION�FEE ._ __ � �� r SUBJECTTOTHEWOFKERS'COMPLNSATIONPROVIS�ONSOFSECTION3]MVFTH ISSUANCE '`�yO � Y � � CA�7�F('ISHA/�eL�R FlTMWITHCOMPLVWI 14N ....__ �' _ .. _ � OATE��.���[,�APPLICAtdT. ._ . . �� � ._— SMIP __" 3M L<. .... ' � � . . � ENERGV P/C — .-- — .— J WAflNIN(�,FAILUPE TO SECUflE WORKERS'COMP[N6ATIOk CAVEAAOE IS 11NLAWFUL,AN�SN B LL SU&IECTANEMPLOVERTOCPIMINALPENALTIESANOCIVILFINESLIPTOONEHU4DRED7HOUSANO ENERGVPERMIT ' ` :l +` �•.� DOI.LtRS(5100,0001.IN AODITION TO THE COSTOF COMPENSATpN.DAMAGES AS PqOVIDED FOR IN -----�.==--.e-�'y- ���y�;�.�' � Q SEGTION 3]oe OF TF7E LABOR CODE.INTEREST,ANDATTORNEI"S iEES. RETENTION FEE: ._,_ - 5 oCONSTRUCTIDN LEN�ING AGENCY PRE-ALT FEE: _ _ ' qIHEREBYAFFIqMUNOERPENALTYOFPERIURYTHATTHER[ISACONSTFlUCTIONIENDINCAGENCY ______ FOflTHE PERFORMANCE OF THE WORN FOR WH�CN 7HIS PERMIT IS ISSUED(SEC.30W,CIV,C.�. i`�' W "' _ �' � lENOER'SNAME__' _" _ ___-'--'-_ I'.. _" ' ' F- IENDEq'SADDRESS__ _____ _. .-..-.-..- � 70TAL FEES � � ICERTIFYTHATIHAVEREADTHISRPPLICATIONANDSTATETHATTHEA60VEINFORMATIONISCORRGCT. � �' IAGHEETOCOMPLVWITHALLCITYANDCOUNTYOqDINANCE5AND5TATEtAWSRf�TINGTOBUILDING , � CONS TION.ANO HEREBV AUTHORIZE RLPRESENTATIVE IS COUNTY TO ENTEN UPON THE ROPERTY OR INSPECT rv PUReos . COMMENTS � J � "_ _ _ ¢ P T7EE NAME(PRINT) f,, _,_ __ v� S-���IA' NL C'. L',,A U l.� �''� - Z - ' � _ (q SIGNATUHEOfVEHMITTEE aTE ' " G , � RECPL N ._ PAID BY _ VALlDAT10N . 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