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HomeMy WebLinkAbout10734 (5) CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT I �.c 21660 E.Copley Drive Suite 190 PRESS (909)860�3195 Fax(909)861-3117 �'""°, BCJILDIIVG PERMIT APPLICATION FIRMLY � JOBSITE �2� �1.,:�,,,[ �� APPLICATION PERMIT P/C o ADDRESS ���`� ��73`� DATE fdUMBER N c� ISSUE TYPE OCC APN T TRACT �qTE_�Z � �'7 CONST. GROUP p OWNER o ADD S - ZONING SETBACKS z CITY GI�IP TEL. ��-�Qa(� FRONT RW fl o APPLICANT �E�� � �4 SIDE/SIDE STREET RW C] � GONTRACTOR SIDE ❑ ADDRESS p PROPOSEDUSE 3VI+i l��e� s �K� . �' CiTY ZIP TEL._ _ �' 0 ARCH/ENGI -� ✓��' �z DESIaNER NO.pWEL. NO. NO. a ADDRESS � CITY 21P TEL. UNITS STORIES BEDROOMS cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AqEANALUATION � OWNER-BI:IIDER DECLARATION SFRiADD/REM O 0 1 HEREBY AFFIRM UN�ER PENALTV OF PERJURY THAT I AM E%EMPT FHOM iHE CONTRACTORS U- G2f899JC3fPDff W CENSEIAWFOR7HEFOLLOWIN6REASON�SEC.7037.SBUSINESSPNOPqOFESSiONSCO0E:MIYCINOR (n U f,pUNNNR11CHqE0UIRE5A�ERMITT�CONSTqUCT,ALTER,IMVROVE,�EMOLISH,ORFEP4IRANYSTqUC• ' W TURE,PRIOR TO ITS ISSUANCE,AL50 flE�UIPES THE APPLICANT GOR SUCH PFRMIT TO FlLE A SIQNED W PatiolDeck STATEMEPIi 7HAi NFQq SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTflACTOflS LI- � CENSE LAW(CHAP B(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE WSINESS AN�PRO� � POOUSP3 0 FESSIONSCOD RTHATHEORSHEISEXEMPTTHEPEFROMANDTHEBASISFpqTHEALLEGEDE%EMP- (� V T�ON.ANYV TqNOF5ECT10N7a31.58YANVpPPIICANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z Re-Roof ACIVILV ALTYOFNOiMOflETHANFNEMUNOREODOLLARS(Y500).�: I,ASOWNEROFTHEPROPERTV.ORM�EMPLOYEESWITHWAGESRSTHEIfl50LECOMPENSATION. �0 Z Commeicial WILL DO THE WOPK.AN01HE STRUCTURE IS NOT IN7EN�E0 oq OFFERED FOR 3ALE 15EC.1oaa,BU51• � J �. NESS AND PROFESSIONS CODE:THE CONTRACTOFS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PqOPERTV VA108UIIA5 OR IMPROYES 7HEREON,AND WHO DOES SUCN WORK HIMSEIF Oq NERSELF ON �� THFiOl1GHHI50RHEROWNEMPLOVEES,PROVIUEDTHAiSUCh11MPROVEMENTSAPENOTINTEN�E00H m QOFFEREDFORSALE.IF.lIOWEVEFZTHE8l11L�INGOflIMPROVEMENTISSOLOWITHINONEYEAR�FCpMPLE- z� �TION.THE OWNEH-BUIIDER WILL HAVE THE BUFOEN OF PROVWG TtIAT HE OR SHE DID NOT BUILD Oq � IMPROVE FOR THE PURPOSEOf SALE). W , CI,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCANTRACTINGWITHLICEN6E�CON7MCTORS �� TO CONSiqUC7 THE PROJECT(SEC.7044,BUSINE55 AND PHOFESSIONS CODE:TiE CONTFACTONS�I� V0II1dY10� � A�J.AREA_ W CENSEUWWESNOTAPVIYTOANOWNEflOFAPROPERTYWM09llIL�SOR�MPROVE5h1EREON,AND . �. WHOLOMRACTSFORSUCHPROJECTSWITHACOMfiAGTOR(57LICENSEDPURSUANTTOTMECONTflAP QUANTITY DESCRIPTION FEE � TOR3lIC�ENSE LAW.). 0 pYIAM EXEMPT UN�EF S[C. �0 I`_� __�B.8 P.C.FOH 7HIS REASW� � � }y U �, -- CL �OATE_. � �OWN U 0 W � LICENSED CON AC FS DECLARATION � W � I MEREBYAFFIRM UNOER PENALTV OF PERJIIflY THA IAM UCENSED UNDEA PROVISIONS OF CNAPiEP � d' sfCOMMENCINGW17H3ECTION7000�OFDIVISION30FTHEBLISINESSANDPROFES510N5CADE,ANO Z � MY LICENSE IS IN FULL FOqCE AND EFFECT. m �'�` �� UCEN5E CL0.SS _ LIC.NO.__ ,_ _ � F J V DATE CANTRACTOR__ �' a W - �� WpRKERS'COMPENSATION DECLARATION � � ' N� I HEflEBYAFFIRM UN�ER PENALTY aF PERJURY ONE OF THE FOLLOWING DECLAflAT10N5: Z Q � _IHAVEANDWIL�A7AINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKER&' _ � CqMPEN6ATION,ASPROYIOEDBVSECTION3]00pFTHEIABO�iCODE,FORTHFPERFORMANCE �U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSAT�ON INSURANCE,AS REOUIRED BY SECTION yp� � Q37000F THE LABOfl CO�E,FOR THE PERFORMANCE OF THE WORK FOR WHICHTHIS PERMIT 15 L�Sg•V ; J ISSUED.MY WORKERS'COMPENSATION INSURANCE CARFIER AND POLICY NUM6ER ME: CONSTRUCTION �,_ _ j cnRaiea_ _._ _ __ PLAN REVIEW � PaICYNUMBER_ ELECTRIC Q - `y . . T�, 0 (fHISSECT/JNNE�NOT8E00MH.E7EDOFTHEPERINfISFORONEHUWI7EDDOLINiS(5100)ORLESS} PLUMBING �.���1'�'� '�'45•;k3 W � Z I CER7IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL _ �'�'� (} SHALLNOTEMPLOVANVPEHSONINANYMpNNER50AS108ECOMESU&IECTTOTHE � WOHKERS'COMPENSATION LAWS OF CALIFOHN10.AN�AGREE THRT IF I SHOULO�ECOME INSPECTION FEE _ . = SU&IECT TO THE WOfiKEHS'COMPENSATION PROYISIONS OF SECTION a70oOF THE LABOfl ;1* �;` o Q CADE.I 5HALL FOflTM'ITH COMPLY WITH THOSE PROVIS�ONS. ISSUANCE _�_�, vt�LS /S. � � SMIP �W��� �.. .. —j`�:,` .� p DATE'___ APPLICANT. _ ___ � — W j WARNING FAILUflE TO SECUPE WORKERS'COMPENSATION COVLRAGE IS UNLAWFUL.NVD 5FIALlBE ENERCaY P/C . �y SU&IEGTANEMPLOYEFTOCRIMINALPENALTIE3ANOCIVILfINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DDLI.AFiS(5700,000),IN/�OI710N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTpN 37080F THE LABOq COOE,INTEPEST,ANDATfORNEN6 FEES. RETENTION FEE: , ' p CONSTRUCTION LENDING AGENCY PRE-ALT FEE: , I � � IHEflEBVAFFIqMUNDEflPENALTYOFPEMURVTHATTHEREISACANSTRUC710NLEN�INGAG[NCY FOR THE PEpFORMANCE OF iHE WORK FOR WHICH 7NIS DEAMIT IS ISSUED(SEC.30B7,CIV.C.). Z W � � IENDER'SNAME �_ �_ - � �- LENDEfYSADORESS _ __ W ICERTIFYTHAiIHAVEREADTHISNPPLICATIONAN�STA7E7HATTHEA80VE1NFORMATIONISCORRECT. TOTALFEES 61�00 � IAOREETOCOMPLYWITHALLCITYANDCOUNTVOFIDINANCESAN�STA7ELAWSqEUTINGTOBUILDINO � CONSTRUCTION,ANDHEREBYAUTHORIZEHEPRESENTATIVESOFTIIISCOUNTV70EN7EqUPONTHE Z ABOVE�M NTIONED�R07ERTVFOFlINSPECTIONPURPOSES. � �� � 1 � �g /� COMMENTS j vV��W m PEflMI P 7 ., . . d –" � . (/� TUHEOfPEflMITfEE � A = RECPT.NO._ PAID BY �I 3 _VALIDATION ~ WHITE—De Amen Co YELLOW—Finance Co PINK—Assessor Co GOLDENRO�--File Co GREEN— Ilcant's Ca . Pa PY. PY� PY� PY. APP PY ----. .. ;..._ ..,.,,� w....,. ` � .� � ,-� .�i"'l�'.�_" i; ,m„ � j __..,. 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