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HomeMy WebLinkAbout11922 (5) " ��_ CITY OF DIAMOND BAR - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w � 21660 E.Copley Drive Suite 190 . ����AM� BUILDING PE (RMIT APPLICATION _�/ ,�� FIRMLY o` ADDRESS ��{'"i� D�/�'-„— �` DATE CATION � � �� NUMBER � �C 1 c.� ISSUE TYPE �CC APN_ LOT TRACT DATE CONST. GROUP °C OWNER 0 LL" ADDRESS (.�,8 ZONING SETBACKS Z CITY n ZIP ral � TEL. � � REART RW ful S APPLICANT TEL. � t-� SIDE151DE STREET RW iJ � CONTRACTOR SIDE n__! � ADDRESS e � CITY�'.`-[�.-� ' ZIP TEL. �/ � PROPOSED USE o ARCHIENG/ � DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS _ STORIES _ BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O 1 HERE9Y RFFlRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRAC70R5 LI- G2fHge/C7fpOIS W CEN5ELAWFOHTHEFOILOWINGRFA50N(SEC.7o3t.58USINFSSANDPflOFE5510q5LODE:ANYCIT'OR (n � COUNiYNMICHREqUIRESAPERMiiTOCONSTHUCT,ALTER,IMPROVE.�EMOLISH,ORHEPAIRANYSTRUC- �jJ pati0/OeCk W TURE.PflpR TO ITS ISSUANCE.A150 REW IflES THE RPPLICANi FOR SUCN PEflMIi TO FiIE A 516NED W .� STATEMENT THAT NE OR SHE IS LICENSED PURSUAN7 1'O THE PROVISIONS OF THE CONTHAC70RS ll- s CENSE UW(CFUPTEH 9(CDMMENCING WITH SECTION 7000)OF OIVISION 3 OF TME 9USINE55 ANO Pfl0- � POO�Sp3 S FE&41DNBCDDE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBFSISFORTHEALLEOEDEXEMP- U TION.ANYVIOLATIONOFSECTION7WI.SBYANVAPPLICAYTFORAPERMITSU&IECTSTHEAPPUCANTTO Z qe.App� � A GIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLURS(t5ao).j: ^ UI,tiSOWNEROFTHEPROPER1l'.ORMYEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, L� COrt1f11BfC18I � WILL DO THE WOHK,lJJD THE STRUCTURE IS NOT IP7�ENDEO OR OFFERED FOR SALE(SEC.7044.BU51� J y HE6SAND PROFESSION6 COOE:THE C6MRACTORB LICENSE LAW DOES NOT APPLV TO AN OWNER OF ? PROPERTYHM1iOBU1LD50RHJIPROVE5hIEREON.ANDWHODDE55UCHWOHKHIMSELFORHERSELFOfl m � iFiRIX1OHHI50RHEROWNEMVLOVEES,PROV�DEDTHATSUCHIMPRWEMENTSARENOTINTENOEDOR QOFFEREUFORSPLEIF,F104lEVER7F�EBUILDINGORIIAPROVEMENTISSOLDWITHINONEYEAROFCOM7LE- Z TpN,TME OWNER�BUILDEH WILL HAVE TME BUflDEN OF PROYI�G THAT HE OH SHE DID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SALE7. L71,AS ONRJER OF THE PROPEHfY.M1 EXClU51VELY CONTRACTING WI7H LICENSED COMRACTORS Q TO CANSTRUCT THE PNQIECT(SEC.7014,BUSINESS ANO PFOFESSIONS CODE:THE CONTRACTORS LI� Vy�Uaf10� __ ADJ.AHEA __ W CENSELAWDOESNOTAPPLYTOANOYMEROFAPROPERTYN'HOBUILDSORIMPpOVESTHEftEON,AND � WFIOCONTRACTSFORSUCHPRQJECT6WITHACONTRAC:OR(S)UCENSEDPURSUANTTOTHECON7RAC pUANTITY DESCRIPTION FEE Y TORSIICENSEUW.). e� � � � ❑I AM EXEMPT UNOER SEC.,__.__. _�8.e P.Q FOR 7HIS REASON Q � _�_ _._'__""'_ ¢ DA7E ONRJEP ____"__.' U � LICENSED CONTRACTORS DECLARATION W � IHEREBYAFFIRMUIiDEflPENAI.TYOFPERJURYTHATiAMLICENSF.DUN�[RPROVISIONSOFCHAPTEfl � � �, d Y(COMMENCING WITH SECTION 7000)OF DNISION 30F THE BlJ51NE55 AND PpOFESSIONS CADE,AN� Z X MY UCENSE IS IN FULL FORCE AND EFFECT, ��a� m ^,�,/)t '] Lll /�J^+� `'� � � (� l.y Q LICENSE GLASS ,�v✓� LIC.NO._�__����/ / � V DATE �•�CONTRACTOR�_ .Lr_ II4 d W f � WORKFHS'COMPEN5ATION DECLARATION 1,r�j G�� -� N v� V � IHEREBYAFFIRMUNDEflPENALYYOFPERJURVONEOFTHEFOLLOWING�ECLARATIONS: Z Q � __IlIAVEANDWILLMAINTAINACERfIFICA7EOFCONSEN7TOSELF�INSUREFOPWOPICERS' 2 COMPENSATION,ASPROVIDEDBYSECTION37000F7HELABO{iCADC,FDATNEPfRFORMANCE 'U OF THE WORK FOp WHICHTHIS PF.RMIT IS ISSUED. � � ��IiiAVCANDWILLMAINTAINWOW(EriS'CON.PENSATIONINSURANCE,ASPE�UIHEOBYSEC7iUu � 37000FTHELABOHCOOE,FOR7HEPERFOFMANCEOFiHEWORKFOqWHIGl7THISPERMITIS -- — � IS5UED.MVWORKEHS'COMPENSATIONINS RAtJCECARRIERANOPOLICYNUM6ERARE� CONSTRUCTION .. _.. ._ �j CAflf71EN._�_� �_� PLAN REVIEW __ �. _ _' '__—'_"'_ '_' '""--' ^�f �"• p �1 ZpOLiCYNUMBER � '` ��r+-t- ELECTflIC _„__..__ ______. Q � i �•� Q (TF{4SSECP(XdNE�NOTBEC�APLEfED�1HEPEiUM�SFORQYEHIF�DRE�Od..lAf75(5 � �Essa � PLUMBING _ _____ �� -1__�_— W MECHANICAL Z I CERTIFYTNAT IN THE PEflFORMpNCE Of THE WONK FOfl WHICH THIS PERMIT IS ISSUED,I ..-- ----.-- ------ �J SHALLNOTEMPLOYANYPEFSONINANYMANNERSOASTOBECOMESUDJECTTOTHE (n WORKEFS'COMPENSATIONII�WSOFCALIFORNIA,ANDAOREETHPTIFISHOULDBECOM[ INSPECTIONFEE ,_____..__. ,____„_ = SU&IECT TO THE WURKERS'COAIPENSATION CPOVISi�NS OF SECTION 37000F THE LABOP ' � � ' CApE,ISHAL�.FORTHWITMGOMPLYWITHTHOSEPROVI5KKJ5. (SSUANC -- - __' _'_—"" '""'_"—"""" "__ � �.="��_ SMIP p OATE: APPLICAN7:_ __ _'___"'_"'__ — -'—-- � ENERGV P/C - ---�---- -------�..----� J WARNINGFAIIUflETOSECUREWORKEflS'COMPENSATIONCOVERAGEISUNLAWFUL,AN�SHALLUE �L SUBJECTANEMPLOVEATOCRIMINALPENALTIESANDCIVILFI.YESl1PTOONEHl1NDRE�THOUSAN� ENERGYPERMIT OOLLARS(Si0D.000),INPDDITION70THECOSTOFCOMPENSATION.DANAOESASPROYIDEDFORIN --- -""-----"--- --'-- � SECTION37080FTHELA60HCODE,WTLI7EST,ANOATTORNEY'SFEES. 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