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HomeMy WebLinkAbout16223 (20) ^ ��_ CITY OF DIAMOND BAR r/� ) DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES „ 21660 E.Copley Drive Suite 190 . �W (909)86(�3195 Fax(909)861-3117 PRESS � �'A�'� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �/3� �aN� � �L � DATE CATION 2,� � NUMB R�" C \'��'�'� o ADDRESS � APN LOT TRACT DATE � ONST. V OCC � p OWNER � GROUP " ADDRESS �. ZONING SET8ACK5 w FRONT RW ❑ � APPLI � Z � TE� ' SIDE/SIDE STFiEET RW ❑_ �� CONTRACTOR SIDE _______ _ __ C 1_ _ � ADDRESS p PROPOSED USE CITY ZIP TEL. ,,_..______--• o, ARCWENG/ /V�/ , DESI(iNE � ` _ rs_I��.� � � ADDRESS�/ G� ��/r�� � .+Z� NO.DWEL. �-/U NO. � ��n G 1� Z�P �E, �� T UNITS___ STORIES BEDROOMS � � cn DESCRiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OINNER-BUILDER DECLA ATION SFR/ADD/REM O •--_.._._� -- p I HEHEBY AFFIRM UN�ER PENALT/OF�EMIRV THAT�AM EXEMPT FROM TFIE CONiHACTORS LI� G8fe9BICdfP01t W CENSEUWFORTHEFOLLOWINGHEASON�SEC.7WI.SBUSINESSANOPFOPFSSIONSCADE:ANYCITYOR (/� CJ �pUNryWHICHREWIRESAPERMRTOCONSTqUCT,ALTER.IMPROVE.DEMOLISH,ORREPAIPM1YSTiiUC- W pollO/DECk � TURE,PRIOR TO RS ISSUANCE,AL50 REDUIRES iHE APPLICAN7 FOfl SUCH PERMIT 70 FILE A SIGNED W � STA7EMENT THAT HE OR SHE IS LICENSE�PUflSUANT TO THE PqOVISIONS OF THE CANTRACTORS U� � C CEN&E LAW(CHAPTER B�COMMENCIPIG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- POOUSPB � FESSqNSCODEJORTHATHEORSHEISEXEMPTTHEflEFflDMAN[]THF.BASISFORTHEALLF.GEOEXEMP- � V TION.ANYVIOUTKKJOFSECTION7031.SBYANYAPP�ICANTFORAPERMI7SU&1EC75THEAPPUCANT70 z RB-ROOf � ACIVIL CENALN OF NUT A/ORE THEN FIVF.HL'NDREO OOLLARS(5500).): `^.I,ASOWNEFOFTHEPflOPEATY,ORMVEMPLOYEESWITHWA3ESA5THFIRSOLECOMPENSAT!ON. L �,UI71111EfCIflI WiIJ.UO THE WOIiK,AND THE STRUCTURE IS NOT INTENOE�OR OFFEflED FOR SALE(SEC.7044,BUSI� J NESS 1W0 PROFE5510N5 COOE:THE CANTRACTORS LICENSE LAW DOES NOT AGPLY TO AN OWNEH OF � PROPERTYW110BUILDSORIMPROVESiNEFEON.ANDWHO00E55UCHWOfiKtIIMSELFORIlEHSELFUH � � 7HRDUGMHISORHEflOWNEMP�0YEE5,PROVIDE�THATSUCHIMGROVEMENTSARENOTINTENDEDOfl m � OFFEPED FORSPLE IF,HOWEYEi�iHE AUIIDMG OR IIAPROVEEIENTIS SOI D WITHIN DNE VEAR OF CAAI%.E� � Z 7qN,THE OWNER-BUILOER WILL HAVE?HE BUfl�EN OF PROVINO THAT HE OR SHE OID NOT DUILD OR , � IMPROVE PoR TME PURPOSE OF SALE). � ❑I,AS OWNER OF THE PROPEFTiY,.M EXCWSIVELY CANTRACTING W!T4!IICENSE�CONTRACTORS � TO CON6TRUCT TME PRQIECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONYRACTORS LI- Vtl!ll8ll0l1 ADJ.AFlEA � LLI CENSEUWOOESNOT�PPLYTOqHOVlNEROFAPROPEHT'YdHOHUILD50RIMPROV�5THEFEON,AND --- ------� - � WFIOCONfRACTSFOHSUCHPflOJECT5WITHACDYTRACTOH(5)LICENSEDPURSUAN770THFWNTRAG QUANTIIY DESCRIPTIUN FEE �' � TORSLICENSELAW.). __ � � � Q l 1 I IM EXFM T UND .SEC. ____ ___ _ .8 P�.FOR THIS RLASDN Q _. _______ __ � -- --'- U � - - � — ---'— o ` _ � -- — T. .i.... W - — LI NSED CONTRACTORS DECLARpTION -� W � 1 HEREBYAFFIRM UNDER PENALN OF PEFUURY THA7IAM LICENSFD UNDEA FROV!�ION£OF CHMTER � p� Y(IXkAMENCINO WITH SECTKKtl 70fA)OF DIVISION 3 OF THF BUSIYE55 ANU PRUFFSS!ONS GO�I:,ANU Z _ X AAY UCENSE IS IN FUf L F CE h`1D EFFLCT ,�--��((" � Lll y .t�-�V ys � J __ � � LICENSE CLASS ✓ I.IQ NO. a ` � F- - W DATE � �� ____CONTRAC OA -._` ��.,�,�CL a —� � � WO KERS'COMPENSATION DEC HATION Q ' � fHERF.BYAFFIR11aUNDERPENAITYOFPERIUHYONEOFTHEFOLLOWiNGOECLARAilONS: � � Z Q � __.__INAVEANDWILLMAINTAINACERTIfICATEGFCAVSEN?TOSELF-INSUPEFOf1WORKfRS' _ --' COidPFkSATIC�4,A5VFOVIDEOBYfiEC?ION3]auOFTNEI/�90RCOUE.FORTHEPERFOHIUANCL U Q Of THE WORK FCR ri111CM TNIS FEfiMIT IS ISSUED. � Q � .I HAyEM'0 YlILLMAIN7AIN WORKERS'COMf'ENSATIOY INSURANCE.AS NE(�UiHEG HY Sf.CTION � � � 3700 0E TiE LAl30R C07c.FOR'fHF:PEfiFOFAiRACE OFTNE WORK FOR WHICHTHIS PEHMIT IS „ ISSUEU.MV WORKF. 5'CAf�RPMSA`ION INSUSiANCE CARRIER�Ntayoucv r �neEa nn�: CONSTRUCTION � _____.__�����R - "' — ' _' � � '�� � L �� �'ZtiM.� • �`------- caaHiEH _ ._e__�_._-___ PLAN REVIEW .���-e-_� _ -- -- � � zPa.�cvr+uMa�H___ " � _.Z._.� _.._.._.___._._. ELF.CTRIC _ � _ d ri (IF0.S5[CTqNNEE�NO7BEO:YNF".F.fFDUF7VEPEPhYTISFORGP:EHINS)REDDOLLMZS(5100)OFLESS} PLUME3ING ____ � ICF:R'fIFVTHATINTNEFEPFORMANCEOF'fHEWORKFOpWHICHTHISPEAMITISI55L'ED.1 MECNANICAL � SHALLNOTF.MPLOYrWYPEfl30NINANYMMI�ERSOASTUB[CAMFSUdJECTTOTHf. -- � WORKERS'COMPENSATIO4LAWSOFCPIIFCRNIA,AN�AGREEThITIFISHOULDRFGOMF. INSPECTIONFEE _ � SUAJECT7 HE FKERS'COM7FNSAT7Ov7pOVI510NSOF F ION31000FTHElABOR —� � ._ _- WQ�,ISH FO THWITHCAMPIYWITH.THOSEP 7sron. ISSUANCE O � y j� Lq WDATE:._zj _ AVPLICANT: _�� � ___'_. SMIP �._��_tI-�ll CI I'--_,__-_.. _a. -� WARNING:F UflE SEC RE WORKEPS'COMPENSATION COVERAGE IS UNLA U. [)SHpLL BE ENERGY P/C � J � SU&IECTANEMPI ERT CPIMINAI.PENALTIESANDCIVILFINESUPTOONEHU D THOUSAND ENERGYPERMIT ' � OOLLARS(f700,OW),INAD TIONTOTHECOSTOFCAMPENSATION,DAl,tAGESA� IDEDFORIN ' � SECTION37080FTHEUIBORCODE,INTEREST.ANDATTORN[V'5FEES.— — RETENTIONFEE: .__ B�. � d CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: _____—_..... ___ O Q IHEREBYAFFIRMIIN�ERVF.NALTYOFPERJURYYHAT7HF.REI.SACONSTRUCTIONLENDINGAGENCY n- PoFTHEPERFOftMA4CEOfTHEWOFlKFORWN�CHTH�SPERMITI5ISSUED(SEC.3097,CIV.C.). �'�� � � W -"""'_-'_"'...._'_"-_"__""'...—"""'_'_' SLENDCR'SNAME _._.._...._ ..,_...'-_- > -"_"_ _"'__"_— — F- LENDER'SADDRESS _ —_._--__.___ .---- W TOTAL FEES ����� 4�� ��� t I CERTIFY THAT 1 HAVE REA�TF115�PPLICnT'�ON ANU STATE THATTHE AROVE INFORMAiION IS fARRECT. { �y_ 1 AGREE TO COMPLY W1TH ALL ANO CAUN fY OROINANCES AND STATE LAWS REIATING TO BUII,DING � 1'ftUCTYJNANOHEHEEE���Y LHUNZEFEPRESENTATIVF OFTNISCOUNTYTOENTEFUPONTHE A VE-MEMTNNJE�PflOPE�Y'G]Il INSPECTION PUR�S Z l l i COMMENTS----�-------------------------- ---�--- � �� � � �-��- t ��---- --- ------�--------'--�-----'—' ---- m P RSIITfEE NAME(PR�NT) Q _'..."___ .� N - .-.. 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