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HomeMy WebLinkAbout14082 (16) _ �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES Ijg, . 21660 E.Copley Drive Suite 190 �'A W (909)860-3195 Fax(909)8613117 PRESS ��'9�'" BUILDING PERMTT APPLICATION FIRMLY . - , . o DDRiESS !C7�,���,��I�I_� ��ll L^ � DATEICATION ��� ��� NU B R � 4.'�� �!C � APN LOT � TRA T .�,.�''i"�y ,� / ISSUE TYPE OCC "R'�ii6? DATE _CONST. GROUP p OWNER � ` ,� o ADDRESS /� `'�� ZONING SETBACKS - -- � ' � CITY � ZIP P EL. FRONT R�ly ❑ S APPLICANT v TEL REAR ❑_ � SIDE/SIDE STREET RW ❑ CONTRACTOR � � ir � ( � � SIDE � ❑ � ADDR S � a PROPOSED USE a CITY o ZIP 1 TEL. o ARCH/ENG/ � � DESIGNER Np.DWEL O. NO. ADDRESS — — UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.ARErVVALUATION Q OWNER-BUILDER DECLARATlON SFR/ADDIREM O 8 I HEFE9Y AFFIRM UNDER PENALTV CF PERJURY THA7 1 AM EXEMPT FROM THE WNTRACTORS LI- Gar2gelCdlport � CENSEUWFORTHEFOIIOWINGREASON(SEG7031.5BUSWESSANOPROFESSIONSCOOE:AMYCITYOR (n COUNTVWHICMflC4UWE5APERMITTOODNSTRUCT,ALTER,IMPROVE,DEMOLiSH.ORHEPAiRANVSTqt1C- W P8ti0/DBCk W NRE,PRIOH TO ITS ISSUANCe,ALSO FEQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICEIJSED PURSl1ANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE LAW{CHAPTER 9(COMMENCINa WI7T1 SECTION 7000)Or DIVISION 30F THE BUSINESS AND Pq0- �'1" POOUSpe FESSqNSCODE)ORTIATHEORSHEISE%EMPT'iNEREFHOMPN�THEBASISFORTHEALLE0E0EXEMP- (� TION.ANYYiOLATIONOFSECTION7031.5BYANYAPPUCANTFORpGERMITSUB.IECTSTHEAPPUCANTTO Z Re-Root F ACMLPENALTYOFNOTMORETHANFIVEHUNDREDOOltAR5�350oj.): � ❑I,A50WNEROFIHEPPOPERT',OqbiVEMPIDYEESWiTHWAGESASTHEIR57LECOMFENSATION, C� COfI1R18fC121 WILL DO TME WORI(,MI�THE STRUCTURE IS NOT INTENDED OR OPFEREO FOR SALE(SEC.7041,BUS!- J � NESS AND PROFESSIOkS CODE:7ME CON7RACTORS IJCENSE LAW 60ES PH�T APPLV TO AN OWNER OP � PROPERTY VhlO BUILDS 6R IMPROVES 7HEREON,ANO WHO DOES SUCFI WORK HIMSELF OR HERSELF OR � iHROUGHHISORHEROWNEMPLOYEES,PROYIOE�THATSUCHIMPRDVEMENTSAFlENOTINTENDm�R m � OiFEPEDFORSALEIF,FiOWEVER,h1EBUIlOINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- ' z TION,THE OWNER-BUILDER WILL HAVE THE B�IRDEN OF PqOVIldC iHAT Hf.OR SHE DID NOT BUILD OR = IMPROVEFORiHEPURPOBEOFSALE�. W ❑I,ASOWNEROFTHEPROP[f1TV,RME%CLLISIVELYCONTRACTINCWI7NLICXNBEDCONT'RACTORS (= TO CONSTHUCT TME PR0.IECT(SEG.7a4,BUSINESS AND PROFESSIONS GODE�THE CCNJTRACTORS LI- V27UflI1O11 ADJ.AREA__ W CENSE UW DOES NOTAPP�Y TO AN ONMEfl OFAPROPEflTY WNO BUILDS OF IMPROVES THEFlEON,AND —� -- � WHO�NTHhCT5FOq5UGiPR0.1F.CT5WITHACCNd7flACi09(S)LICENSEDPURSUANT?OTHECONTRAG� QUANTIIY nESCRIPTION FEE � TORSLICENSEUW.). � � ❑I AM EJfEMPT UN6ER SEC._. 8.6 P.C.FOR THIS REASON Q + r� � _ — U � - ---- OC �. OATE OWNER____ ,_ � r''� /� � t^".,�r,.F 11.1 t_{CENSED CONTRACTOiiS DECLARATION ,� �� , �- � i HEREBY AFFIRM UNDER PENATY OF PERJURY 7HAT i AM LICENSE�UN�ER PHOVISICNS OF CHAP?ER � ' p�� d Y(COMMENCINGWITHSECTION7000)bFDIVISION30FTHEBUSINESSAiJDPPOFeSSION5CO0E.AN� Z �-�� X MV UCENSE IS IN FULL FORCE AND EFFECT. � Y , LLI L. � � UCENSE/C�-LA+SS+� � q LIC.NO."-�'��- � � •��y� '-e ?'° 9� �� VDATE .`\,. ..�'6 _,�+'��g GONTRAGTOR_j.�......�. i1��,,,�� 0- ^._,a, ��LA w —�—�__� � 4VORKERS'CUMPENSATION DEC!.l,RATfON ¢ � � I HEHEBV AFFlHM 11NDER PF.NAISV OF PERJIJRV ONE OF THE FOLLCWING DECURAilONS: Z ^(;� :"'� ,j P � _IHAYEANDWILLMAINTAINACERT7FICA?EOFCONSENYTOSELFWSUREFORWORKERS' x � ) � -'r _�F �� � L ��') W9APENS0.TION,ASPROVIDEDBYSECTION37WOFTHELABORCCDF,FOPTHEPERFORMARCE U �� �-['�` .? .-� OF 7NE W4RK FOR WMCH THIS PFPMIT IS ISSUF.D. W � • � �---�-- �`�i'�.'"t�/`���)''P.�&�Tt�C`r . ;Cd`�"'� , � W _INAVLMNpWILLAIAINTAINWOFlNERS'C9MPENSATI NINSUAANCE,ASREOUIREDBYSECTION � 37DaOF'HELABORCflDE,FbHYHEfERFORMANC OfTHEWORKFOflYlNICHTHISPERMITIS ISSUEC.MY WORKERS'f�t1MPEN5ATION INSURAN CARfl1ER 'D POLIGY NUPABER AFE: CONSTRUCTION Q (, ' �, CAFRIER__y�_. � PLAN REVlEW _! _ ZPOLICY:dUMBER_ .. ' y ' � .i ELECTRIC � ��� � �tws�c�n!�rioreEca,+rt�ooFn-�rEw,ur�sk;aav[inNar�aoauas(ftoo)oRLEssy. PLUMBING � Z I C,ERTIFYTHAT INTHE PEFFOAMANCE 6F 7l1E WORK FOR 1YHICHTHIS PERMIT IS IS5t/ED,I MECHANICAL � (`j SHALLNOTEMPLGYANYVERSONINAIVYMANNEfl50A5TO8ECOMESIJBJECTTOTHE � WORKERS'COMPEMSATIONLAWSOFCALIFORNIA,ANDAGREETMATIFISHOULDBECOME INSPECTIC�NFEE � SUBJECTTOTHEVKJf1KER5'COMPENSATIONPqOV!SIONSOFS'cC710N37000FTHELA30R �p' '�5 3 j COOE.I SHALL WHTHWI7H CQABPLY WITHTHOS�PROVISIONS. ISSUANCE � � a �'�.�'��.d 'a�"- p DATE:_��s,j har. APPLICANT: �_��t.- SMIP ���'y � .,y., .. �i,. �..�....� ��`"�- L±4.iy. J > V�/ � ENERGYP/C F�i�,I;��"�p�,se'+. :�uz�r�,-, ._-,. J WARNINGFAILURETOSECUREWORKEFS'GOMPENSATIONCOVERqGEISUMAWFU N� NALLBE i 1e.v a.._v» �j;�,�y� �h � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUN� TH USAND ENERGYPERMIT f � OOlLARS�f10o.000),iN ADDITION 70 THE COST OF COMPENSATION,DAMAGES AS PROV FOR IN � � SECTION 37oA OF THE LABOR CODE,INTE(iEST,AN�ATTORNEV'S FEES. , RETENTION FEE: _ a CONSTRUC710N LENDING AGENCY PRE-ALT FEE: O � IHEREBYAfFIRMUNOERPEN4LTYOFPERJUftVTHATTHEREISACONSTRUCTIONLENDINGAGENCY _` FOR THE PERFORMANCF OF THE WORK FOR WhIICH THIS PERMIT IS ISSUE�(SF.C.3D87,CIV.C.�. W � LENDER'SfJFME___ _ _.____ „ F— LEN�ER'SADORESS _ � TOTAL FEES � IGERTIFYTNATIHr1VERFADTHISAPPLIGAfIONANUSTAIETHATTHEABOVEMFORMRTIONISCARRECT. � � I AGREE i0 COMPLV WITH ALl CIT'ANO COUN7Y ORDINANCES AND STATE L4W5 REIATING TO BUILDING � � CONSTPUCTION,AND HEREBY AUTHORI2E REPRESENTA71VE5 OF THIS COUNTY TO ENTEP UPON THE z FBOVE-MEMh�NEDPROPERTVFORINSPECTIONPUftPOSES. COMMENTS � ���4a�C� � J � �� � � . ' y e _—'--_'____.__'.—..__..__.___—_ m PEAMI7TEE NAME(PRI Cn ^ ,4�° .19 � SIGNATURF.OF PEFiM1TT DATE = HECPT.NO. _ PAID BY VAL.IDATION ~ WHITE—D artment Co YELLOVJ�inance Co PI K—Assessor Co GOLDENROD�ile Co GREEN— aP PY, PY. 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