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HomeMy WebLinkAbout17462 (25) f---�� ` CITY OF DIAMOND BAR -�� � � 1 I3EPARTMENT aF C�MMUNITY&DEVEL�PMENT SERVICES 1 � 21825 E.Copley Drive (909)860-3145 Fax(909)861-3117 PRESS "�'%•���� BUILDIN�PERMITAPPLICATION FIRMLY y JOBSITE ��y,�1jE�R��y��� � ,�/ APPLICATf i PERMIT P/C o ADDRESS_ �� DATE i� " �"'� P NUMBER 174��# °-° APN LOT Z TRACT ISSUE /° t TYPE OCC DATE �2 P 1e�' C'�✓ CONST. GROUP p OWNER � ,�'U p ADDRESS ZONING SETBACKS z CITY .T�I�i61DAI '� 13/L� ZIP Q�'��TEL. O FRONT RW ❑ � APPLICANT TEL. REAR ❑ ¢ SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � � ADDRESS {� ,p � CITY ZIP TEL. PROPOSED USE ��N!i `C�� ��+ �'.`�'�'� o ARCH/ENG! '� � � • Z DESIGNER w N(�;DWEL N . NO. � ADDRESS 11NITS STORIES � BEDROOMS � C17Y ZIP TEL. � � DESCRIPTION. S�Qy.Ft FACTOR PSF ADJ.AREANALUATION � O OWNER-BUILDER DECLARATION SFR/ADD/REM �y , � I HEREBV AFFIRM UN�ER PENI�TY OF PEFiJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G81'flgE/Cflfp0lt ' W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31.5BUSINESSANOPROFESSIONSCODE�,ANVqTYOR (n U' COUNTYWHICHFlEQUIRESAPEFMITTOCONSTAUCT,ALTER,IMPROVE,DEMOLISH.ORREPAIRANYSTRUC- W PafID/OBCI( WTURE:PRIOR TO Ii5 ISSUANCE.11L50 HEOl11RES THE APPLICANT FOR SUCH PEflMR TO FILE A SIGNED W ��, STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO'HE PROVISIONS OF THE CONTRACTORS LI- � �,�, CENSE L4W(CHAP7Eq 9(COMMENCINO WITH SECiIGN�000)OF DIVISION 3 OF TF:E BUSlNESS ANO PRO- POOVSj/d �.'. FESSIONSCODE)Oq7{{ATHEOR$HEISEXEMPTiHEREFROMAND7HE6ASISFORTHEALLEOEDEXEMP- (� V', TIaN.ANVVIOLATioNOFSECiION'�7a3�.5BVPNVAPPl,ICANTFORAPeRMITSUBJECTSiHEAPPLICANTTO Z qe-Roof �'�, A CIY�I�EN�ALTV OF NOT MORE THAN FIVE HUN�HED OOLIAFS�5500).): Yi711.f�50WNEROFTHEPROP�RTY,ORMVEMPLOYEESWITHW/GESASTHEIRSOLECOMPENS(iICN, O CD(I71110fCidl � WILL'D�Y7HE WOAK,AND iHE STRUCTURE IS NOT INTEN�@�OR OFFEqED FOR SALE(SEC.7044,BU51- J � � 'NESS AN�PROFESSIpNS CO�E:THE GONiRAC70F5 LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PROPERTV WHO BUILDS OR IMPRdVESTHEREON,ANp WHODOES SUCH WORKHIMSELFORHERSELF OR �� 'THROUGHHISORHEqOWNEMPLOY�ES,PFOVI�E�THATSUCHIMPROVEMENTSARENOTINTEN�EDOR m Q�,; OFFEREDFORSALE.IF,HOWEVER7HEBLIIL�INGORIMPROVEMENTISSOLDWITHINONEYEApOFCOMPLE- Z� TION,7HE OWNEfi-BUILDER WILL HAVE THE BURDEN OF PROVING TMAT HE OR SHE�I�NOT Bull�oR _. IMPROVE FORTHE PURPOSE O�SALE�. w�., ❑I,AS OWNER OFhIE PROPERTY,AM EXCLUSIVLLYCONTRACTINO W�TH LICENSE�CONTRACTORS ��' TO CONSTRUCT THE PROJEC7(SEC.7044,BUSINESS ANO PROFESSION6 CO�E:THE CONTRACTORS U- VeWaliOn � ADJ.AREA W', .CENSELAWDDESNOiqpPLVTOANOWNEROFAPRDPERTVWHOBUILO50RIlAPflOVESTHEREON,qND ' �,� �.WHpCONTflACT5FOR5UCHPROJECTSWITHACONiRACTOR(S)LICENSE�PuqSIJANTTOTHECONTRAG QUANTITY PDESCRIPTION FEE Y. 'TORS LICENSE LAW.). � ❑I AM EXEMPTUNDER SEC. B,8 P.C.FOR iH15 REASON Q � `Ir�� �� ' (� � U � DATE OWNER � � W � LICENSE6 CONTRAC70RS DECLARATION W � Q � IHEREBYAFFIRMUNOERPENALTYOFPERJURYTHATIAMLICENSEDUN�EqPPOVI510N50FCHAPT�R � � � i9�COMMeNCINGWiiHSECTION7o0a)OF�IVISION30FTHE6USINESSA�DPROfE5510N5CODE.AND z `X MY UCENSE IS IN GUt�FOfiCEAN�EFFECT. m � �LICENSE CLASS LIC.ND. j V DA7E CON7RACTOR 6J. LL] � WORKERS'COMPENSATION DECLARATlON Q � 1 NEREBV AFFIRM UNDER PENALTV OF PFRIURV ONE OFTHE FOLLOWING DECLARATION&: z Z __IHAVEAN�WILLMAINTAM/ICERTIFlCATEOFCONSENTTOSELFINSUREFOqWORKERS' a � . COMPENSATION,ASPROVIpE08YSECTION37ooOFTHELABORCODE,FORTHEPERFORMANCE W Q OFTHEWORKFORWHICH7HISPERMITISISSUED. � �� �IHAVEAN�WILLMAINTAINiWORKERS'COMPENSATIONINSVRANCE.ASRE-0UIRE�BYSECTION Q' � 3��OOFTHELABORCO�E,'FORTHEPERFORMANCEOFTHEWOqKFORWHICHTHISPERM1T15 1 J ISSUED.MY WORKERS'COMPENSATION INSl1RANCECAqR1ERAND POLICV NUMBERAftE: CONSTRUCTION D � � CARRIER �— > PLAN REVIEW POUCY NUMBER �y �'t. Q�� - ELECTRIC +-(� a�,a � (IHISSECT1uNNEmNOTOEO�MREfE�OFTHEPERHUTISi9RONEHUN�RmDOLiARS�yY00)ORLESSJ. PLUMBING Z� IGERTIFYTHATINTFiEPERFORMANCEOFTHEWORKFORWHICHTHiSPEqMITI5lS5uF�.l MECHANICAL '(,3 SHALL N07 EMPLOY ANY PERSON IA ANY MAryNER SOAS i0 BECOME SU&IECTTO THE (q WORKERS'CON,pENSATIONL4WSOFCALIFORNIA,ANDAGRFETHATIFISHOl1LDBECOME INSPECTIONFEE _. SUBJECTTOT;{EWORKER5COMPENSATIONPROVISIONSOFSECTION3�DOOF7HELABOR p�� �� CODE,I SHALL FORTHWITH,COMPLV WITH THOSE PROVISIONS. ISSUANCE ,,,� � p DATE: APPUCANT: SMIP ��T� W J WFRNING FAIW RE TD SECl1RE Y✓ORKERS'COMPENSATION COVERPGE IS UNLAWFUL,AND SHALL BE ENERGY P/C � SU&IECT AN ENPIOYERTO CRIMINAL PENALTIES ANO CIVIL FMES UP TOONE HIJNDqED THDUSAN� �'1 "�1 � DOLLAflS(EiOo,000),IN ADOITIONTO THE C05T OF COMPENSATION,DAMAGES AS PFIDVIDED FOR IN ENERGY PERMIT -' �-��`�. j, ' � SECTION3]OBOFTHEIABORCo�E,IMEREST,ANDATTORNEY'SFEES. RETENTIONFEE: �°g �q y OCONSTRUCTION IENDWG AGENCY pqE-ALT FEE: B.J�C Ce �' __ S � IHEREBYAFFIRMUNDERPENALTYpFPERJURYTHATTHEREISACONSTRUCTIONL�NDINGP.GENCY FOfl THE PERFORMA�CE OF THE WORK FOR WHICH THIS PEqMIi IS ISSUED�SEC.309�,CIV.C.). � � w — -- I_"_,�-r„ � �'�. ' LENDER'SNAME '=- - ___,_... ,__-.......,_—'.—'-.. I—' LENDE9'SAD�RE55 w�, ICERTIFYiHAi1HAVEREAfITHISAPPLICATIONAND57ATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �! /o�� p�� IAGqEEiOLOMPLYW1iHPLlCITYAN�COVNTYOR�INANCE5ANO5TATElAWSREI.ATINGT08UiLOMG V l �„ ', CONSiRVCTION,ANDHEREBYAUTHOqIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z , ABOyE-MENTIONE�PROPERTYFORINSPECTIONPVFlPOSES. �-CQMMENTS � �a o S B GI-�l�tl �3LC _ ---- m' PEfiMITTEENA (PqINT) / d � ` 1 � [1) �, SIGNATURE ERMITTEE OATE � RECP7.NO. 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