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HomeMy WebLinkAbout16664 (32) CTCY OF DIAMOND BAR ��' ��� 1 DEPARTMENT OF COMMUNI'IY&DEVELOPMEM SERVICES I 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 RESS `�•� BUILDING PERMIT APPLICATION FIRMLY Q A�0 RIESS �I DD .J. A�Q[Y1Q/L���C� {J�U i� APPLICATION il PERMIT f I n /C o DATE V NUMBER� p � APN�1� LOT� TRACT I�� DA EE 1 ONST. GRO P p OWNER ^ � "' ADDRESS C� � In ZONING SETBACKS . w �. � FRONT _�"�C 15� RW O z CIN ZIP��. TEL. R REAR ❑ g APPLICANT ` «• '�T TEL. �� "�3I'�r!'�� SIDE/SIDESTREET RW p � CONTRACTOR �� M.^ SIDE p � ADDRESS � ` ` ;�' �, � pROPOSED USE T � � CITY I 21P '20� TE c. w ARCH/ENG/ z DESIGNER , ' ~�'� NO.DWEL NO. NO. nW. ADDR�SS . �� UNITS � STORIES .�_BEDROOMS�A � CITY U ti d ' ZIP '�'>r TEL, y J���3 - ,L ) � DESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION � OWNEH-BUILDER DECLARATION SFR/ADDlREM O p I NEREBY AFFlRM UNDER PENALTY OF PERIURY iHAT I M1 E%EMVT FHOM 7HE CONTMC70R5 LI• G3f2g0/CflfpOA W CENSEUWFORTHEFOILOVlP16REASON(SEC.7071.SBUSINESS�V7�PROFESSIONYCOCE:ANYCITVOR (n (� Ct7UNTYWHICNREOt11RESA7ERA/IT7000NSTFiUCT,ALTERIMPROVE.O[MOUSH.ORREPAIRMIYSTRUG W Pdti01O0Ck Z TURE.�RION TO ITS ISSUANCE,ALSO REW IRES THE A7PlICANT FOR SJd/7ERIIIT TO FILE A SIGNE� �L� STATENENT THAT HE OR SNE IS LICENSED PVliSUANT TO THE PROYi5lON5 OF 7HE CONTfUCTOHS LI� W � CENSE U'N(CHAFTER Y(COMM[NCINC WI7H SECTION 7000)OF DIViSqN�OF THE BUSINESS AND PRO- � PooVSpa FESSIONS COOE)OR iMA7 ME OH SHE IS EXEMPT TMEREFHOM AND TNE BA515 fOR TNE ALLECED E%EMP• V TION.ANYVpUTqNOFSEGTION7071.SBYANYA�PIICANTFORAFERMITSUB:ELiSTHE�PP�ICANTTO Z Re-Fioof A GVIL FENAITV OF NOT GORE THAN FIYE HUNDRED�OLUNS�f5oo)): 0 OlASOWNEROFiMEPR07EHTY.ORMYEIAPLOYEESNnTMWAGESASTHCIRSOLECOMPENSATqN, O COmmercial , Z WILL DO THE WORK,M10 TNE STRUCTl1RE IS NOT INfENDEO OR OFGEREO FOR SA:E(SEC.70�<.BUSI- J NESS AND DROFESSIONS CODE:TNE COhTMCTORS LICENSE LAW DOES NOT APPLY 10 AN OWNER OF � PROPERTVMA108U0.DSORIIdPROVESTHEREON.ANDWHODOESSUCHN'OiiKMt4ISELFORHERSEIFOR � Q THROUCNHISORHEFOWNEUPLOYEES,FROVAEDIHATSUCHUAPROVFMEN'SARENOTINTENDEDDR m � OFFEREDFORS.LLEIF,FqWEYERTMEBU:DINdORIMPPOVEMENTI550LOWiTIwNOhEYEAROFCOMPLE- Z TqN,TME OwNER-BUILDER Y/iLL HAVE THE BURDEN OF PROviNO TMA7 HE OH SHE DIO NOT BUILD OR � MPqOVEFOqTHEVURPO5EOf5ALE} O l�ONMER OF THE PROPERi1;AM EXCLUSNEIV CONTMCTINC WRH LICENSED CONTRACTORS � TO CONSTRUCT THE PRO.IECT(SEC.)M�.BUSiNESS ANO PPOFESSiONS CODE.THE CONTRACTORS L4 Valu0ti0�1 ADJ.AREA W CENSELAWDOESNOTAP7LYTOANONTlEROFAPROPERTYWHOBl11LD50RIM7RJVESTHEREON,/WD � VAqCAMRACiSFORSUd10R0.1ECTSVIITHACONTMCTOR(S�UCENSEOVURSIIAVTTOTMECONTiUC- QUANTITY DESCRIPTION FEE Y TOiiS UCENSE Uw.�. � OIAME%EAIPTUNDERSEG. B.BFQFORTHISREASON U � LL ¢ DATE Ow4ER V Z W � UCENSED CONTRACTORS DECLARATION � W � IHEFEBY�FFIRMUNOERPENALTYOFPERRIRYTHATIAMLICENSEDUNDERPROVISIONSOFCMMTER V. d Y�COMMENCINOWITHSECilON7000)OFDIV�SION�OF7HEBVSINESSMDPROFESSIONSCODE,AND Z MY�ICENSE IS M FULL FOFCE AND EFFECT. m q G� � LICENSECLASS, O LIC.NO.�CiJ �'� � V DATE � �_ CONTFUCTOR�����A�C� � G a W � WORKERS'COMPENSATION�ECLARATION , U Vq� ("(� �JG.�^ WDrLC N IHEREBYAFFIRMUNDER7EN/�LTYOFGERJURYONEOFTNEFOLLOWINCDECURAiIONS. Z ( 2 ,� � Q � �IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS' _ /1 'T,�- COIAPENSATION.AS PROVIOED BY SECTION Y/Oo OF TME LABOR COOE,FOR THE VERFORMANCE 'U �� OF THE WORN i0R WMICH THIS PERMIT IS ISSUED � +n � � W _IMAVEMIDYALLMAINTAINVJORKERS'COV7ENSATIONINSURANCE,�SRCOUIREOBVSECTION Q 9TOOOF TME UBOR CODE,FORTHE PERFORMANCE OFTFIE WORN FOFl WNICHTHIS PERIAR IS ISSUED.MYWORKERS'COMPENSATqNINSUR CECARR�ERAnDPOLICYNI:MOERARE: CONSTF�UCTION J j CARRIER � � �'„ '�^���n• PLANREVIEW Z va�cvNur.+oEA ��- ELECTRIC ¢ �ssEcrionr�mwreFoor.a�Erman[ccn.rrsw�or.E�uwa�oaiiuu6,ro)rn�ss) PLUMBING � Z I CERTIFY THAT W THE PERFOPMANCE OF THE WORK FOR WMICN 1Hi5 PEf,MIT IS ISSUE�.t MECHANICAL (} SMALLNOTEAIFLOVANYVERSONPIMNMANNCRSOASTOBECOMESUBJECTtOTHE N WORKERS'COIdPENSATI0NUW50FCALIFORNIA,AN�AGRFETHATIFISMDUIOBECOME INSPECTIONFEE S SUBJECTTOTHEWORNERS'CWaCFNSATqNPRON510NSOF5ECT101137000LTHELABOR CWE,I ALLJf ORTIMIITNCO�.�PLYWITH7HD5�PRONSKKJS. � / ISSUANCE � DATE: `�' /DI APPLICANT. `�•�'✓IJ� -. �NC�iuli� SMIP 0 � ENERGY P/C WARNINC:FAILURE TO SECURE WORI(fR5'COMOENSATION COVERACE�S UNUW FVL,/�ND SHALL BE � SUOJECT/WEMPLOYERTOCRIMINAIPENALTIESIW�CNILFWESUPTOONENUNOREDTMOUSAND ENERGYPERMIT OOLURS(S 100.0001.W b�ITION TO THE COST OF�pM GENSATION.DAMAG[5 AS GPOVIDED FOR IN J SECTION770BOFTHEUBORCODE.INTEREST,MlDATfORNEYSFEE4. 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