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HomeMy WebLinkAbout10965 (5) � i i �'r.s : ���* � - -- CITY OF DIAMOND BAR � � COMMUNITY DEVELOPMENT DEPARTMENT � � ,,,. 21660 E.Copley Drive Suite 190 PRESS (909)860-3[95['ax(909)861-3I 17 �'""�`� BUILDINGPERMiTAPPLICATION ��� FIRMLY � JOBSITE !�r I�i� Y"l r% ?Q � APPLICATION ' -��PERMIT� �P/C o' ADDRESS a��'� i !a/��•-•+6'r7 DATE NUMBE # c� ISSUE TYPE OCC APN LOT T T DATE CONST. GROUP °C OWNER / � � O � � ZONING SETBACKS W ADDRESS ` - �. t FRONT RW ❑__ z CITY ` MfJ , ZIP TEL. - ! p APPLICANT � � TEL. REAR ❑__ Z SIDE/SIDESTREET RW Cl_ a CONTRACTOR __ SIDE C1 Q ADDRESS • '� -s � PROPOSED USE � CITY��`_ ZIP ��TEL, � w ARCHlENG/ � z DESIGNER -- NO.DWEL. NO. NO. � a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL._ N DESCRIPTION SQ.FT. FACTDR PSF ADJ.AREANALUATION � �- � OWNER-BI:ILDER DECLARA710N SFRlADD/REM I O I p 1 HEREBY AFFIRM UNDER PENALTY OF PERJUFY 7HAT I AM EXEMPT fROM THE CONTfiAC70R5 Lb G8fd9BICefPOfi W CENSEUWFOR7HEFOLLOWINGREASON(SEC.�a31.5BUSINE55ANDPROFESSIONSCODE:ANYCIT'Oq (n U COl1NTYWFl1C]iHE0l11RESAPERMITTOCONSTpUGT,ALTER.IMPROVE,OF.MOLISH,ORREPAIRANYSTRUC� I Z TURE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCN PEFiMIT TO FILE A SIGNED w PBIIO/�BCK � W STATEMEM THAT HE OR SHE IS LICENSED PURSUANT TD THE PflOVI510N5 OF THE CANTHACTORS LI- w � CEN3E LAW(CHAPTER 9(COMMENCMO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PRO- u' PooUSpa � FESSIONSCO�E)ORTHATHEORSHEISE%EMPTTHEREFFOMANOINEBASISFORTHEALLEGLOEXEMP. C7 I V TlON.ANYVIOLATICNOF3ECTION703f.5pYANYAPPI.ICANTFOAAPERM173V&IECTSTHEAPPLICAN7T0 Z qe•Roo} � ACIVIL�ENALTVOFNOTMORETHANFIVEHUN�RE��OLURS(SSoO)_�� � Q OI,A50NMEROFTHEPROPERTY,OqMYEMPLOYF.F.SVNTHWAGESASTHEIR50lECOMPENSATION, � Commercial � Z WILL DO THE WORK,AND THE 5TFUCTUFE IS NOT INTENDFU OR OFFERED FOR SALE(5EC.701d,BU51- J NE55 AND PROFESSIONS CODE'TH[CONTRACTORS LICENSE LAW DOES NOT APPIY TO AN OWNER OF t � VROPERTVWHOBUILDSORIMPROVESTH[REON,ANDWHOOOESSUCHWCRKNIMSELFORHERSELFOR m � � THFOUGt1NI50RMEROWNEMPLOYEES,PflOVIDEDTHATSUCHIMPRDYEMENTSAPENOTINTEN�EDOR W oFFEREDFORSPIE.IF,HOWEVER,7HE�UILDINGORIMPHOVEMEN7ISSOLDWITHINONEVEAROFfAMPLE- � TION.7NE OWNER-BUILDER WILL HAVE THE BUFDEN OF CROVMG TMAT HE OR SHE DID NOT BUILO OH � = IMPROVE FOR TNE PURPOSE OF SAIE�. y �J I,AS OYfNER OF THE PROPF.RTY,AM EXCLUSIVELY COt6TRACTINQ WITH LICENSED CON7RACTORS � TO CONSTRUCT 7NE PRQIECT(SEC.706d,6USINE55 AND PIIOFESSIONS CADE:THE CONTRACTORS LI� V8IU0I10� _„____.__ ADJ.AREA � W CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPERTYWH09UIL�SORIMPROVESTHEREON,AND � � WHOCON7MCTSFORSUCHPP0.IECTSWITHACONTRACTOq(S)LICEN5EDPUHSUANTTOTHECONTRAC- QUANTITY �ESCRIPTION FEE Y TORS LICENSE LAW). � ❑1 FM E%EMPTUNDER SEC. 8.8 P.C.FOR TMI5 REASON Q � O ----- V � ------ -----... ¢ W DATE ,_, OWNER_ F � � _'_'_' '--'_— W i � LICENSED CONTRACTORS DECL4FATION W � � I NEREBY AFFIRM UNDER VENALTY OF PERJURY THAi l AM UCENSED UNDER PROVI510N5 0F CHAPTER � � � 9(COMMENCING WITH SECTION 70ao�OF pIVISION 3 OF TNE BUSINESS ANO PROFESSIONS CODE,AND Z `' � X MY LICENSE IS IN FULL FORCE AND EFFEGT. m � . � � LLI � LICENSE CLASS UC.N0.__��6� _�___.,._.. j �,y �� ��I J �j DATE__�,y _.,��� CONTRACTOR______S�=—[.r a W � WORKERS'COMPENSATION DECLARATION � = Q ; � 1 HEREBY AFFIRM UN�ER PENIILTY OF PERJUfl7 ONE OF THF.FOLIOWING DECLARATIONS: U � C/) Z Q � I HAVE AND WILLMAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSl1PE FOR WORKERS' 2 V CAMPENSATION,AS PROVIDED BV SECTION 37o00F TME IABOR CODE,FOfiTHE PERFORMANCE U ¢ OF THE WORK FOR WHICH THIS PEFlMIT IS ISSUED. � i � W �1 HAVF,AND Wi�LMAINTAIN WORKERS'COMP£NSATION INSURANCE,AS fiEO�JIP.ED BY SEC?IOM f — Q 3'IooOFTHELABDRCODE,FOflTHEFERFOFlMANCEOFTHEWOPKfOHWHfCHTHISPERVITIS � ISSII[D.MY WORKERS'CAMPENSATION I SURANCE CARRIER AN�POIICY NUMBER ARE: CONSTRUCTION _ _ � Q 4 � CARRIEq�. �� PLANREVIEW __ __ � Z P�I.ICYNUMBER � ���P • � �� '� ELECTRIC _._ ; Q �� (fHISSECTIIXdNE�NO'fBLCOMoLFfEDOFTF1EGEfUMI5i7N70NEFRNDRFD�OLLARS(5100)ORLESS} PLUMBING __ ��' Z I CER71fYTHAT IN TME PEFiFOPMANCE OF THE WOHK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL _ ___ ___ � CJ' SHALLNOTEMPLOYANYPERSONIVANYM/WNERSOASTOBEGOMESUBJEGTTOTME � � WORKERS'COMP[NSATIONLAWSOFCALIFOHNiA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE ,__ SU&IECTTOTY.EWORKERS'COMPENSFTIONPftOVISiON50F5F.CT10431oaOFTHELA80F _—i�, ' i. __� t ' ( OCOnE,iSHALLFOXTHWI7MCOMPIVWITHTH 'PROVISIONS ISSUANCE __ _._ ; p DATE:__,��APPLIGANT: __--������ SMIP . '_'..___'_ _— ' J WApNING:FAIIURE TO SECURE WORKEHS'COMDENSATION COVERAGE IS 11NLAWN!.,PNO SHALL 9E ENERGY P/C , ,__ __ � LL Sll&IECTAN EMPLOVEfl TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDFED 7HOUSAND ENERGY PERMIT �• � ���V�" �OLLARS(S1oD.aoo�,IN ADDITION TO THE COSTOF COMPENSATION.DAMAGES AS PROVIOE�FOR IN � '---T=� � —" '- � � SECTION3�aeOFTMELABORCO�E.INTEpEST,ANDATTORNF.Y'SFEES. RETENTIONFEE: __ __.__ � i � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEFEBYAFFIRMUNOEFPENALTVOFPERJf/RY7NATTHEAEISACOVSTqUCT10NLEN0INGAGENCY � FOR THE PERFOFMPNCE aF THE WORK FOR WMIGH TNIS PERMIT IS I55UE0(SEC.3097,CIV.C.�. -"----" - Z W ' '__ _" � LENDER'S NAME_ .—.—... ...__.__. _ F— LENDER'SADORESS_.__ _.._.__.. ___--__— � ICERTlFYTNATIHAVEREADTFUSAPPUCpTIONANDSTATETHATiHEA80VEINFOflMATIONISCORREC7. TOTF\L FEES ��C t � IAGREFTOCOMPLVWITiIALICITVANDCOUNTVORDINANCE5AND5TATELAWSRELATINGTOBUIL�ING �� V � CANSTRUCTION.ANO HERE6Y AUTHORIZE R[PF[SE ATIVES OF THIS COUNTY TO ENTEfl UPON THE � Z A80VE�MENTIONED PROPERTY FOR INSPECTION PUR OSES. COMM NTS_ E � `�'('I � ��� _ �'a'f€-�$- '.��'^�C�� _�d— ; m pERMITTEE N • � N �jy,��� ¢ "' '�''��___�'.�"'�-��'�� ""---- --_1 ' �,I�-7t� I = SIGNATURE OF PERMITfEE �A 9 �✓V�' RECPT.NO. ` PAID BY _ VAL�DAT, � j ~" WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GHEEN—AppllcanPs Copy � , 1 �_�.��,.�._.T'r.�l'i i � T�r�T� � -�-- � ;--,—;._.�._._i�� : ` I � � _�----- � _ -�---;___ ` . � . � , = . � i � i � ; � f � � I � -- � �� � _ _ � , i � s � , _ - , , , , , � � , _ � , � , � , � 3. r ' ( � � ' _` ' I �. �_ j I � 3 � � � i �; � � �'� I � , � . � '� ��� �:.. � �� i I � ��.r �� � � ,�• � ! � ._ { ; - ,— I � i � I ' -� i _ ' _ ! 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