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HomeMy WebLinkAbout12330 _�o CITY OF DIAMOND BAR ' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVIC C;. 2166D E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � ����9M'�� BUII.DING PERMIT APPLICATION � FIRMLY � JOBSITE �Q APPLICATION c/ PERMIT �� � P/CGJ� o AQDRESS �j/Z� �CG'I�'rI C� C�{'/'' U�/1� DATE ���� ��� fd NUMBER � # `����" c� . ISSUE TYPE OCC APN_� L9T TR T DATE CONST. GROUP p OWNER C?d� 0 i �3� �`- — s ZONING SETBACKS p ADDREjj S fG�Li�°PC 't � Z `CITY L�ili/�1 d �E'ZIP .TEL.� � FRONT RW I_I � APPLICANT t' . L. �i z1T REAR ❑ __ � � SIDE/SIQE STREET RW LJ � CONTRACTOR � F (' SIDE l-I___ � ADDRE S � � C ` � �` � pROPOSED US� �q' ` � �'�S �� � � CITY ZIP TEL�,�.,�T -� • Q ARCH/ENG/ � _ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDAOOMS V_ � CITY ____ ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/A�D/REM O 1 HEREBY AFFlRM UN�EF PENALT'OF PERJl1RY THAT I AM E%EMPT FROM THE CONTRACTORS LI- G8(8A0/C2fpOff W CEN9ELAWFORTHEFOLLOWINGREASON(SEC.7037.56U91NE5SANDPROF[SSIOYSCODE:ANYGTYOR (n � COUNTYWHICHREWIRESAPERMITTOCON5TRUCT,ALTEFl,IMPHOVL,DEAAOLISH,ORREPAIRANYSTRUC- W P0[IO/D9Ck W TURE.PpqR TO 175 ISSUANCE,ALSO REQUIflES THE APPIIGANT FOR SUCH PERMIT TO FILE A SIGNED w STATEMENT THAT HE OR SHE IS 4�CENSEO PUHSUANT TO THE PROVISIONS OF Th1E CONTRACTORS LI. � CENSE lAW(GMqPTER e(COMMENCIh6 WIiN SECTION�a0o)OF OIYISION 3 OF THE BUSINE55 AND Pft0- � POOVSp3 FESSIONSCODE)ORiHATHEORSHEISE%EMPTTNEREFPOMANDTHEBASISFORTHEALLEGEUE%EMP- C7 U TqN.ANYVIOLATIONOFSECTICN7031.58YANYAPPLICRNTFORAPLRMiT5U9JECT5�H[APPLICAYTiO z RE-ROOf � ACMLPENALTYOFNOTMORETHANFNEHUNDHE�UOLlARS(5500)J: o C]I,ASOWNEROFTHEPROPERTY,OHMVEMPIOYEESWiTHYlAGESASTH[IHSOLFCOMPF.NSATION, L, COrt11770fCIaI Z VfiLL DO THE WORK,AND iHE STRUCNRE IS NOT IYTENDED OR UFf ERED fOR SALE(SEC.7V44,BIJSI- J NES3 MID Pl�FESSIONS CODE:THE CONTqACfORS LiCENSE Il�W DOES NOT APPLV TO AN OWNER OF �n PqOPERTYNMOBU1LD50RIMPROYESTHEREON�ANDVMODOESSUCHWOAKHIMSELFORFIERSELFOR � � TXROUGHHISORHEROYMEMGLDVEES,PFIOVIDE�THATSUCHIMPqOVEMENTSARENOTINTENDEDOR � QOFFEHEDFORSILL.EIF,HOWEVERTMEBNl01NGORIMPROVEMENTiSSOLDWiTHINONEYEAROFCOMPLE- _ Z TION,THE OWNER-BUILDER WILL HqVE TNE BURDEN OF PROVING THAT HF.OR SN[D:D N07�UILD OR = IMPFtOVEFORTHEPURPOSEOF5ALE1. w [II,ASOWNEHOFTHEPHOPERiY.AME%C1.U51VElYCONTRACTMGWITHLICENSEDCANTHACTORS e�� � TO(�NS7ifl1CT THE PROJECT(SEC.�049.BUSINESS AN�PROFESSIONS CAO['THE GONTRACTOFS LI- V01UflIlIX1 "���r ADJ.AREA W CENSELAWOOESNOTAPPLYTOANON7IEROFAPROPERTYWHOBUII�SOHIMVROVESTNEREON,PND - � Nh1OCANTFACTSFORSIICHPROJECT5WIT4�FCONTHACTOF(5)LICENSE�PUflSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORSl10EN5EUW.). _ ¢ ❑IAM EXEMPT UNDER SEC. B.E P.0 Foq THIS REASON ! U O '____'__""_ � � LL OATE OWNER__ .._ � W � LICENSED CONTRACTORS DFCLARATION W I HEPEBY AFFlFM UN�ER PENAITY Of PERJUPY 7MAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 8(COMMENCWCiW�THSECTION7000jOFDIVISION30FTHE8USINESSANDPROFES510N5f,ODF,AN� Z X AIYL�CENSEISINNLLFONCEAN�EFlECT. m lLl f%`5 �y' t,y � � UCENSE C SS .�_LIG.NO. S /S O / � J ��� l��__._."=_'C V a --- DATE ._�C__d C�_— CONTMCTOR..__._____—� W �� WORKERS'COMPENSATION DECLARATION } � a y U � I HER AFFIRM UNDEH PENAITY DF PE0.IURY ONE OF THF FOLLOWING DECLAfiATIONS: Z a � I HAVEAND'MLL MPINTRIN ACERTIFICATE DF CONSF:NT TO SELF-INSURE('OR WOFlKERS' _ CqMPENSATION.ASPROVIUEDBVSECTION37aoO�THE��f�RCO�E,FUfiTHEp[qKGqMANCE U � OFTME WONK FOR WHICX THIS 7F.FMIT IS ISSUED. � � I HAVEANU WILL MAINTAiN WORKERS'COMPENSATION INSURANCE,AS RF�NRF.O BY SFCTION / '] Q �3]aoOFTHELAF30RCO�E,FOHTHEPFiiFORMPtiCEO�TH[WORKFORWMIGHTMISPEFMITIS - ,II(/� e�L'� _ iSSUEO.MYWORKERS'CAMPE!N�pfIONINSURAN ECFFflIEH/DPOtICYN B:RAflP CONSTRUCTION , _�� .. —... .. � CARRIEfl � `�� �'� .��` PLAN REVIEW + �A b-f f ..� � POLICV NUM�LR_ __� ��r__ '� + � ( �.�� �.'�. __'—'_' z �~ �----------- ELECTRIC e. r__]-1r�..._.—_._. a c: �- + �' , � (THISSECTqNNE�ND.T9ECn.�LETmOFTHEPERM1YTISFURQYElNX�ARED (S7N)ORLESSI PLUMBING �- --.....---.-. Z ICERTIFYTHATINTHEPEflFOHMANCEOFTHEWORKFORNMICHTHISPERMITI51S5UED,1 MECHANICAL ,_____ _._ ____._. _-_ (;j SHALLNOTEMPIOYANVPER50NINANYMANNER50ASTOBECO\1ESUBJECfTOTHE � WORKERS'COMPENSATIOY LAWS OF CALIFORNIA,/1N0 AGRFC 7HA�If"I SHOUl.t19fCOME INSPECTION FEE ________ '• ."' _'___'—_'_ � SL�BJECTTOTHEWOFNEFS'COMPENSATbNPftOVISION50F5ECTION37000FiHELABOR � CADE,ISHALLFORTHWITHCOMPLVWITH SEPROVISIONS. ISSUANCE ____._.__.., .� _.....—_ __'_".... — p DATE:1���APPLicANT: � — ' SMIP "_"_'.._"'__ '_'__"'__�c�b= � ENERGY P!C ---. -------.---- J WAflNINGFAILURETOSECUREWORKFRS' M7ENSATIONCOVFPAGLISUNLAWfl1L,AN�SHALLBE �L SLl&IECTANEMPLOYEftTOCRIMINALPE TIESANOCIYILFINESUPTOOYEHUNDFEDTHOUSAND FNERGVPERMIT WLLAFS($loo,onoJ,INAUUIiION'fOTHF OSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN - - �� --'-- �� J SECTbN3laeOFTNCLAP.ORCODE,INTEREST.ANOATTOflNEY'SFEES. RETENTIONFEE: __. ��n Q � "''_'_' '_—'_"''__ -�—�"_'_ O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �� ,� — �.._ r� �----- �'-�-----., � IHCREBYAFFIRMUNDEHFENALT�OFPFRJURVTHATTHEREI9ACONSTRUCTIONLFNDIkGAGENCV � FOR THE PERFOI7MANCE OF 1HE WOf7K(�OR WHICH THIS PLRMIT IS ISSUED(SGC.3097,CIY.C.). � � � ������ � ��� Z .. ''� r ____ W � LENDEH'S NAME '_—'"'_"_"_'_'".._,..'"—'— "' ' F= LENOER'SADDRESS__ _._._— �--���� � I CERTIFY THAT I HAVE READ THIS APPLICATION�ND STATF.THAY THF.ADOVF INFORMATION IS CORRECT. T TAL FEES � � � 1 AGREE TO COMPLY WITH ALL CITY ANO COUNTY ORDINANCESAND STATE LAWS RELATIYG TO BUIIDING / CONSTRUCTION,AND HEREBY AUTNORIZE REPAEGENTAlIVFS OF 1 kIIS COUNTY TO ENTER UGbN THE �[/_ ZABOVE�MENTIONEDDROPERTVFORINSPECTIONPUHPOS[5. COMMEf}IS 4�" ''��4����_��_.._ _..—._..___ _____— � _'1I��"J l '���/ ! ` —" ' m PER F.E NAME(PRINT) R— '__'_"_"—'—""— ____'_—__ � •� • � �.---- c�i _ --- -------- - ---- - � 5 ATURE OF PERMITTEE �ATE = RECPT.NO.,,.,.___.. 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