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HomeMy WebLinkAbout12624 (11) � i CITY OF DIAMOND BAR ; ---- " -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ' �r�� 21660�.Copiey Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 FIRMLY ' �����9�°� � BUQ.DING PERMIT APPLICATION _ � JOBSITE ( �`� � APPLICATION ,,- PERMIT �9C � � o ADDRESS ���Sy ✓. Y(��C3fI� ��� ���� DATE � � NUMBERr�� # ��� �� '� c� ISSUE TYPE OCC � APN ` , LyO�T TRACT DATE_ CONST. GROUP G p OWNER��LY+fi1��7�P ; " ADDRESS ZONING SETBACKS '� W FRONT RW ❑ _ ; Z CITY ZIP TEL REAR ❑_ g APPUCANT TEL. _ � SIDEISIDE STREET RW ❑_ � � CONTRACTO {�' (yiJ y, SIDE ❑_.____ � � ADDRESS C � PROPOSED USE '� �� T/ - ! � CITY �� t"�' ZIP TEL i?/?7�`:Z�r , t w ARCH/ENG/ � z DESIGNER NO.DWEL. NO. NO. � a ADDRESS UNITS STORIES BEDROOMS � � C:ITY ZIP TEL. � ' � DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION k OOWNER-BUILDER DECLARATION SFR/ADD/REM 4 � I HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMP7 FROM THE CONTRACTORS LI� � Garage/Carport i W CENSEIAWFORTHEFOLLOWINGREA50N(SEC.7031.SBUSINESSAN'JPROFESSiONSCODE:ANYCITVOR U COUNTYWHICHREWIRESAPERMITTOCON97RUCT,ALTER.IMPROVE,UEIAOLISH,OR(iEPAIRANYSTFiUC� W Pa110/DBCk � TUHE,PFlIOR TO 175 ISSUMICE.AL50 RE��IflES THE APPUCANT FOH SUCH PF.RMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT To THE PROVISIONS OF THE CONTRACTORS LI� �� � CENSE lAW(CViAPTER B(COMAIENCING Wlhl SECTIOY 7000)OF OIVISION 30F THE BLISINESS AND PRO� � u' PootlSpa � FESSIONS CODE)ORTHATl1E OFl SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED E%EMP- i V TION.ANYVIOLATIONOFSECTION7031.59YFNYAPPLIGRN�FOPAPERMITSU&IECTSTHEAPPi�CANTTO Z Re-Roof y , ACIYiLPENALTV OF NOT MORE 7HRN FIVE HUNDRED�OLLARS(f500).)� � yC71,ASOWNEROFTHEPROPERTY,ORMYEMPIAVEESWITIiWAGLSASTHEIRSOIECAMPENSATIDN, ❑ Commercial f � N7LL DO THE WORK,AND TME STRUC7URE IS NOT INTENDE�OR UFFEFiED FOR SALE(SEC.7044,BU51� J NESS PND PROFESSIONS COOE'THE CAN'fRACTORS LICENSE LAV�DOES NOT APPLV 10 AN CNNNER OF ' � PHOPER1VWFiOBUILOSORIMPFOVE57HEREON,ANDYhiODOESSl1CHWORKHIMSELFORHERSELFOR m { � THqIX141111I50RMEROWNEMPLOYEES,PftOVIDEDTHATSUCMIMPROVEMENTSARE40TINTENDEDOR i Q OFFEREDFORSOLEIF,HOWEVERTiE8UIL01NGORIMPflOVEMENTISSOLDWITHINOYEYEAROFCOUVLE E � TpN,THE OWNEREUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR = IMPROVEFORTMEWHPOSEOFSALE�. �. w ❑I.ASOVMEHDF7HEPROPERTV./UAERCLUSIVELYCANTRACTIN6WRNLICENSEDCANTf�ACfOHS y ) � TO CONSTRUCT hIE PRQIECT(SEC.7044,BUSINE55 AND PROFfS510NS CODE:THE CONTRACTORS LI� V01U8110f1 ,_,_, 1 ✓. �J.AREA � � CENSELAWOOESNO7APPLVTOANOWNEflOFAPROPERTYWF100UILDSORIMPROVESTHEflEON,AND 1� NM1IOCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOFi(5)LICENSE�PURSUANTTOTHECONTFlAG QUANTITY DESCRIP710N FEE � 1'ORS UCENSE UW.J. � J � o ❑I AM EXEMPT UN�ER SF.C. __.___._... B.i P.C.FORTHIS REASON U . �j _'__'_ � '�. L � OATE — _.._OWNER_ '__' ...'__ U �,. W �4 LICENSED CONTRACTORS DECLARATION W K I HEREBY AFFIRM UNDER PENALTY OF PERJUAV THAT I AA1 LICENSED UNOER PROVISIONS OF CHAPTfR � d '9(COMMENCINOWITHSECTION7000)OFDIYISION30FTHEBUSINESSAhOPROFE5510NSCODEANU z �� MY LICENSE IS IN FULL FORCE AND EFFECT. m }; � LICENSE SS _ LIC.NO.�'� � � � '' � �` V pq7E�S � CONTRACTOR � ._ �� ` �- W �.G' � WORKERS'COMPENSATION DECLARATION ��"3 � N IHEREBVAFFIRAIl1N�ERPENALTYOFDERJURVONEOFTHEFOLLOWING�ECLARATIONS. � � � � Z , � IHAVEAN�INLLMAINTAINACERTIfICATEOFCONSENTTOSELF�INSl1flEFORWORKERS' 2 � � y,,��[^��PENSATION,AS PROVIDFA BY SECTION 37000F THE LABOR CODE,�OR THE PERFORMANCE W " /OFTHE WORK FOR WHICH TMIS PERMIT IS ISSUED. c2 W ��HAVE AND WIIL NAIN7hIN WORKERS'COMPE49ATION INSUFANCE,AS PE�UIftED BY SECTION � Q 3'10o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOFl WHiCH TMIS PERMIT IS ---�� y�� � ISSUE�.MYWOKER5' OMPE IONINSIlRA ECARRIE6R�yDPOLI�CqV/yuMsSanaE. CONSTRUCTION - _, __ _......_ � CARRIER � •� �DI _� �- / �I�J_�[t__. PLAN REVIEW � � _...----.---.-—_-—.- � L ,. zPOUCVNl1MBEfl � � -.— �� ELECTRIC — R a �� �[r Q �m�ssEcrbnhemrrorsea�rEooFn�rErwrr�swaavEE+urAa[ooa. �Sim)on�E . PlUM81NG —�.5��-----.....-------- -- ;�: W MECHANICAL - '# Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOH W'HICH TH:S PERMIT IS ISSUED.I --------------�--���---����--���-- r -" � (,�J SHALL NOT EMPLOY ANY PEfl30N IN ANY MANNFR SO AS TO BECOME SU&IECT TO THE � WORKERS'COMPENSATIONLPWSOFCALIFORNIII.ANUAGREETHATIFISHOULOBECOME INSPECTIONFEE ___ . SUBJECTTO THE WORKERS'COAIPENSATION PRDVISIONS OF SECTI�N 37000F Tfl[L4BOR ��� � �) �r � COEISHA F�OfRTMWITHCOMPLYWI7 HOSEPROVISIONS. `, ISSUANCE .___. __ _.J.�/�_ �; p DATE: �/� � 6 _ APPLICANT: _ '�9 ss�'�/s 7 SMIP � __.__..___.'. l.. «-- € � ENEHGY P!C � WARNING:FAILUHE'fOSECUHEWORKFf7S' PENSATIONCOV[RAGEISUNLAWFUL,ANDSHALLBE ����'��������J---- -- `� � SU&IECTANEMPLOYERTOCflIMINALPEN IESANUCIVILFlNESUPTOONEHUNURE�iHOUSANO ENERGYPERMIT ._.—__—'�____.... ..__ � DOLLARS(f��,OoO�,IN ADDI7ION TO THE COST OF CO!APENSATI04,DAMAGES AS PROVIUEU FOR IN � � SECTION 3]OB OF THE LABOR CODE,IMEREST.AND ATTORNEY'S FEES. RETENTION FEE: ,...._._.,_.-__-.—.--. .--1L--- Gi � CONSTRUCTIONLENDINGAGENCY � RE-ALTF 0�._ _. —..—_-- �� O � � IHEREBYAFFIRIAUNDERPENALTYOFPERJURYTHA7THEREISACONSTRUCTIONLEN[71NGAGENCY ___ ._.._ FOR THE PERFOHMANCE OF THE WaHK fOR W HICH THIS P[RMIT IS ISSUED(SEC.3D97.CIV.C.). � _'__"—"—'__ -- � Z _ "_—___ , W -'.'-----'—' l? LENDER'SNAME___ ---�------ -- .__ __ _ —'_'_ n � LENDER'SAWHESS __ --� ---------...— r C � /y� � � ICEiYfIFYTHATIHAVEREA�THISAPPLICATIDNMUSTATETHp77MEABOVEINFORMATIONISCORRECT. TOIAL FECS � � w I AGRES f0 COMPLV WITH ALL CITY AND CAUNTY OHDINANCES AND STATE lAWS PELATING TO BURDING � CONSTRUCTION,AND H[HEBYAUTHORIZE REPRESENTATIVFS OF THIS COUNTV TO ENTER UPON THE � ABOVE�MENTIONED PROPERTY FOR INSPECTION PURPOSES. Z COMMENTS _..__ -.----- � ! �,//�� //� a---- r�g � �'�4 S�A--i�l_. 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