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HomeMy WebLinkAbout12916 • ^ � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELO _� 21660 E.CopleyDriveSuite 190 PRESS (909)860-3195 Fax(909)861-3117 � �'��'�1� BIIILDING PERMIT APPLICATION FIRMLY £ JOBSITE L. ('� APPLICATION � PERMIT /C , o: ADDRESS = � �� 4' � DATE �� NUM6ER # � APN LOT TRACT� � ISSUE T��/ OCC ` • DATE C�AIST.P I�i E D GROUP p.. OWNER ��� '`, ZONING SETBACKS �1 o ADDR�SS "'` ' ��( FRONT _ O C I O�� [��,t� ❑__ z cirv � , r $ APPLIC N't - y �TEL.� REAR ❑__., SIDElSIDE STREET RW ❑ _ � CONTRACTOR _ SIDE __. _ O___.,._ �_ ADDRESS � ' � `� O �' ? PROPOSED USE --�a l.� . I � 'C,.i 4� �J` w A C E JIC�j��e ' ^„ � - ` " . •- �, , `..,, ._'. �z, DESIGNER ��~ NO.DWEL. �� NO. • ��j" '" �' � a ADDRESS --- • UNITS _ STORIES BED OOMS � CITY ZIP TEL. ^ y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O � I HEREBY AFFIRM�NDER PENALTV OF PEHJURV THAT 1 qM E%EMPT FFOM TME CANTRpCTOflS LI- G2fe JBJC81pOR W CENSEIAWFOR7NEFOLLOWINOREA90N(9EC.7o315BU51NE55ANDPROFESSIONSfADE:ANYCITVOR (n C.� COUNTYWHICHREWIRESAPERMITTOfANSTHUCT,AI.TER,IMPROVE,DEMOLISH,ORREPAIRANYSTFUC- W P2t10/DBCk � NPE,PHIOR TO IT5 ISSUANCE,ALSO qEOUIRES THE APPUCpNT GOR SUCH PERAl1T TO FILE A SIGNED � STATEMENT iHAT ME OR SHE IS LICENSED Pufl5l1ANT TO THE PFOVISIONS OF THE CONTflACTORS LI- � CENSE LAW(LHAPTEH 9(COMMENdNG WRH SECTION 7000)OF DIVISION 3 OF THE BU31NES5 AND PRO� LL POOUSpB FESSbNS OD�E)ORTHA7 HE Oq SHE IS ENEMPT THFREFROM�NO THE BAS!5 FOR THE/LLECED EXEMP� / V TION.ANYVIOLATIONOFSECTION70.91.59YANYA7PLICANTFORAP(-RMITSU&IECTSTHEAPPLICANTTO Re-Roof � J(,� � ACIVIL7ENALTYOFNOTMORE7HANFIVEHUNORED�OLLAq5�35D0).). � ❑I.�SOWNEHOFTHEPHOPF.R'fY,OflN�VF.MVLOYE[SWITHWAGESASTNEIRSOLECOMPENSATION, COITIAIB/Clal ' YALL DO THE WORK,AN�THE 5TRl1CTURE IS NOT I,YTENDF.D OH OfFER'eD FOF SAL[(SEC.70<4,BU51� �l NE55 AND PROFESSIONS CO�E:THE CONTRACTORS UCENSc LAW OOES NOY APPLV TO AN OWNER OF � PROPERTYWFiOBUILD50RIMPROVESTHERF.ON,RNDWHODOES5l1CHWORKHIMSELFORH[RSELFOIi � [t THRIXIGHHISORMEFOWNEMPLOYEES.PROVI�EDTHA7SUCMIMPROVEMEMSARENOTINiENDE�OR � QOFKEREDWflSALEIF,FqWEVER7HEDUILDINGORIMPRDYEMEMIS30lDWITHINONEYEAROFCOMPL[� Z TION,iHE OWNEHBUILOER WILL HAVE THF.NURDEN OF PROVINC THAT HF.OR SHE DID NDi B111L�OR � IMPROVEFORTHEPUFPOSEOFSALE�. , W ❑I.A501VNEROF7NEPqOPEfliY,PA1EXCLLISIVELYCONTflACTINGWRHLIGENSEOCONTRAC70RS , f � TO CONSTRUCT 7ME Pq0.1ECT(SEC.7aba.BUSINE55 AND PROFESSIONS CO�E:THE CONTRAC70RS LI- Va�Uetion__ � ��.i���ADJ.AREA__ W CENSELAWOOESNOTAPPLVTOANONNEROFAPROPEHTYWHOBU!1D50FIMPflOVESTHEREON,MID — � WHOCONTRACTSFORSUCHPROJECTSWIIY.ACONTRACTOR�S)LICEN5EDPURSIIANTTOTNF.CONTRAC- QUANTITY DESCRIPTION FEE Y TORB LICENSE LAW). � J O ❑I AM EXFMPT UNDER SEC.___.. ___B.&P.C.FOR TNIS tiEASON Q ?. U ' — ----- -----�--- [C � DA7E OWNER__._„ '_—'_ U W � LICENSED CONTRACTORS DECLARATION w � INEFEBYAFFIRMUNDERPEfiALTYOFPERJURYTMATIAMLICENSEOUNDEFPROVISION50FGHAPTER � � e(COMMENCINGWITHSF.CTION700a)OFDIVISION70FThIE0U51NESSANDPROf[SSIONSCODE,AND z __ MY UCENSE IS IN FU1A FORCE AND EFFECT. `t m � / �, ��� t� � � LICENSE G�L�A55���+°'J� LIC.N �•�,___. � V DATE� ' � CONTRACTOR_� �* d . lA.l ,�'�'��✓"{w,,,` ./�� J � WORKERS'COMPENSATION DECLAR TIQt� � � � �'�C� I-3i'�. � ,�,, � IHEREBYAFFIRMUNDEHFENALTYOFPENURY04EOFTHEFOLIOWINGDECU q 045: z 0 __IHAYEAN�WIILMAINTAINACE1ifiFICATEOFCON5EN770SELF-INSUREFORWORKERS' _ � COMPENSATION,AS PqOVIDED BYSFCTION 97a00FTHE LABOR CO�F.fOR TNE PERFORIAANCE w � OF'fHE WORK FOp WHICH THIS PF.RMI71S ISSUED. � O w �I HAVE ANO WILL MAIhRAIN WORKER5'WMPENSATION INSUNANCF..AS FE�UIREO BY SEGTION O 370o OF THF.IABOR CODE.FOR THE PER�ORMANCE OF THF.W04K FOR WHICH TMIS VERM17I5 _ ISSl1FD.MV WOAKERS'COMPEN5ATION INS�HANCE CARflIEH ND PO�ICY NUMBER PRE: CONSTRUCTION _ _. �_, _"— '_'_ "��— j ;". �' `7'� . I F� PLAN R[VIEW CARRIER._� '--' ��"— ___ _ '__"'_ "_' _"'_ � POLICYNUMBER � �� ���e�T��'-� ELECTRIC _....---- -.--... .----- -.-_„-.-- � –��'��-�–-t- � (I}6SSELTIONNE�N�TBE�DMPLETEDOFTHEPEfA4TASf"ORONEF7JWFiED (570oMLE PIUMBING _._._ ' ___" ____ __'___ OD Z ICERTIFYTHATIN7HEPEAFORMANCEOFTHEWOHKFORWHiCHTHISPERMIT ISSU ,I MECHANICAL ..___ ____ ___,__.._ _'_—'_ (} SH�LLNO7EMPLOYANYPERSONINANYMANNG�i50ASTOBECOMESLIBJ[Cfl THE � � WORKERS'COIAPENSA710N LAW�OF CALIFORNIA.ANO AGREE 1'HAT I�1 SHOULD BECOldE INSPEC710N FEE __,___ ...—._._ ,—/{ SU&IECITOTMEWOFKERS'COMPENSATIONPROVISIONSOFSECTION37000FTH[IABOR i J� � � CODE.iISHAIL�QT/NW�ITHCOMPLYWI7H� �SEP VISIONS.�/�� �, ISSUANGE „__ ___., . LA" O � �1 y"—`'':ti�-�`.' � /L.. SMIP • p DATE:L.J�_ APPLICANT: ' "_._. -- --'--- - --��— W ENERGY P/C � WARNING FAILl1RE TO SEGURE WORKERS'COMPENSATION COV[RAGE IS UNL�WFUL,AND SHALL O[ '--'- - "'--'--'-"' �- r� �-- u_ SU&)ECTANEMPIOVERTOCRIMINALPENALTIESAN�CNILFWESUPTOONENIINOREOTHOUSANU �hERGYPERMIT � DOL4AR5(Si00.0oo),INAo�ITION70THEGOSTO�CAMPEN5ATIR`I.DAMAGESASPHOVI�f�FORIN --—'- '--"- --'- —-"-"'-- p J SFCTION3]090FTHELABORCO�E,INTF�LST,qNDATTUNNEI"SFEES. RETENTIONFEE: � � �IT�Q3�-�P�i�-�'��.��&It-- ------.. O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: yp��g�y�,7ain n ier�s r. q� .i+IIJ9-�i./A}q i.."�T'�:�xJ.�l'Li-'�---------- � IHEREBYAFFIHMUN�F.f1PENALTYOFPERJURYTHATTHEREISACONSTfit1C?IONIEN[11NGAGENCY ______ _ __ _ _.___, _ FOR THE PERFORMANCE OF THE WORK FOR W HICH THIS VERMIT IS I55UED(SEG 3oB].CIV C J. W .— . „_ � LEN�EH'SNAME_,. -.—... F- LENDER'SAD�RE55___,_ —_—_....,.. � I CE(1TIfY THAT I FiAVE HEAU THIS APPLICATIONANo STATE THF7 THE A90VE INFORMATION IS CAfiRECT. TOTAL f EES � � � 1 AGPEE To COMPLV WITH ALL CITY AND GOUNTV ONDINANCES AND STATE LAWS RELATING TO DUILDING CONSTRUCTION.AND MEflEBY AUTHORRE REPHESENTA7IVES OF THIS COUNTV TO ENTER UPON THE ABOVE�MENTIONED PflOPERTV FOR INSPECTION VURPOSLS. Z r {� COMMENTS.---- ----. ---- --.----- p '� �.. ,�.'fii j� �,. 1 _/"�`�_ V ---- --- — - = LF ��'- Q PE EE NPME(PRIN7) '�`' r u �+%. ��p ,."' _' _- �/,,•�j� ! � cn `' ��'�.4���.-��'� ���CtG'� l�d� �" ----- ---... � � SIQ ATUREOFPEFMITTEE �ASE = RECPT.NO.._ ie PAID BV �,�__VALIDATION_._� � ~ WHITE—Department Copy,VELLOW--Flnanca Copy.PINK—Assessat Copy.GOLDENROD—File Copy,GREEN—Applicant's Copy � r --� ; __ _ �.. _ _ ., . ,:;���� . ,. .;. ' __ _ .. . . .. . .. . , .,. , ' . � � i : � , � � � . � . �, , ' j � ' � '^s. 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