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HomeMy WebLinkAbout14673 (19) C! J�_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ����"��� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE o ADDRESS II��s r• y-�'¢�„�,,,y,��,/ �.G'.!1 ��� �ATEICATIOM'� � NUMBEF� #/C 4D .1 � �PN LOT TRACT ISSUE TYPE OCC DATE CONST. GROUP p d OWNER 1°'�/1��CG 1"��1nd nqt'YL ADDRESS � t .cC _ ZONING SETBACKS � �ITY N '!� __ ZIP q ' TEL."S�� `)9���a�67 FRONT RW ❑_ ,. APPLICAN '�" TEL. S /' REAR ❑_ � � _ -• SIDE/SIDE STREET r] � CONTRACTOR ����OJ��.SC.c� SYr1US SIDE p� ADDRESS �.Z"��Sr' � .M�NA %�iP.v�Y pROPOSEDUSE � � i , � D �CLI✓li J � CITY t�ire a./yr.- ZIP �/.�.f/ TEL..t+i S-�'Y�dY'JCd OARCH/ENG/ z DESIGNER � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES ___BEDROOMS_„ � rn DESCRIPTION SQ.FT. FAGTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADDlREM O 1 HEHEBY AFFlRM UNDER PENALTY OF PERIURY THAT I AM EXEMPT FROM hIE CANTRAC70RS LI- Ger3g8/C2ryort W CENSELAWFORTHEiOLLOWINGREA50N(SEC.7037.SBLISMESSAN�PROFESSIONSCODE:ANYCITYOR (n U COUNTyWHICHqEWIRESRPERMRTOCONSTPUCT,ALTEF,IMPROVE.DEMOLISH,ORAEPAIRANYSTRUC- W PaI10/DBCk z TI1Rk PRIOR TO RS ISSUANCE,ALSD REQUIRES TNE APPUCANT FOH SUCH PERMIT TO FlLE A SIGNED W 3TATEMENT THAT HE OR SHE IS UCEN3ED PUfl9UANT TO THE PROVISIONS OF TNE CONTflAC70RS LI- W � CENSE UW(CHAPTEH B(COMMENCINQ WITM SECTION 7000)OF OIVISION 30F THE BUSINESS AND PRO- LL' POOVSPB FESSIONSOODE�OR7HATHEORSHEISEXEMPTTHEREFflOMANOTHEBA31SfORTMEALIEGEDE%EMP� (� TbN.ANVYIOLATIONOFSECTION7031.5BYANYAPPUCANTFORAGERIAITSLJ&IECTSTHEAPPLICANTTO Z Re-Roof � ACIVILPENNLTYOFNOTMOREI}iPNFIVEHUNDRED�OLtARS(SSOO�J: C71,ASOWNEROFTHECROPEHTY,ORMVEMPLOYEESWITHwAGESA57HEIR50LECOMPENSATION, ❑ CommBfCial VAII DO THE WORI(ANO 7HE STRUCTURE IS NOT iNTEN�EO OR OFfEREO FOR SALE(SEC.7D<4,BU51- J � � NEA4 AMD PqOFESSIONS CODE�THE CONiRACTORS LICENSE LhW DOES NOT APPLV TO AN OWNER OF � PpDPERTY IM�10 BUILDS OH IMPqOVES THEflEON.AND NMOOOES SUCM WORK HIMSELF OR HERSELF OR � THRIXIOHHISORHERONMEMPLOYEES,PROVIDEOTHATSUCHIMPROVEMENT3ARENOTINTENDEDOR m � OFFEREDFORSALE.IFNOWEYEFi,i11EeUILDIN60RIMPROVEMENTISSOLOWI7NINONEYEnROFCOMPLE� TION,iHE OWNEq�UILDER WILL HAVE THE 9UROF.N OF PppVING THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALEI. � ❑I,ASONTIEROFTHEPNOPEFTV,AMEXCLUSIVELVCOMRACTINGWITHLICENSEUCANTRACTORS CC TO CONSTRUCTTHE PHQIECT(SEC.7aM,BUSINESS ANO PROFESSIONS CODE:TNE CONiRACTORS LI- Va1118f10� ADJ.AREA_,___ W CENSEUWDOESNOTAPPLVTOANONRJEROFAPHOPERTYWNOBUILDSORIMPROVESTHEREON,AND �— —"' --- �•• Vh1000NTMCTSFORSUCHPRqIECiSWITHACONTR0.CTOR�S)LICENSEDPURSUANTTDTHECONTRAP (,�UANTITY DESCRIPTION FEE F— TOfi5l10EN5ELAW.�. � ❑I AM E%EMPT UNOERSEC. _B.a P.C.FOfi THIS REASON Q t —_ Y _"'__ U LL. �DA7E_. ____OWNER _..__—_�' U W � LICENSED CONTRACTORS DECLARATION W pC I HEflEBV AFFIqM UNDER PENALTY OF PEfUURY THAT IAM LICENSED UNDEft PRO�dISIONS OP CHAPTEFi � (L 8(COMMENCINOWITHSECTION7oa0)OGDIVISION3DFTHE�l151NE55ANDPFOFE55pNSCOOE.ANO Z �X� A11'LICENSE IS IN FULL FORCEAND EfFECT. m 0 UCENSE CLASS C�/P.J/GY� LIC.NO.�� � � "'_ V DATE �''�7'" �d� _ CONTRACTOR �� " W /� � WORKFRS'COMPENSATION DE RATION .�1�• •� —� 1 a � 1 HEREBYAFFIRM UNDF.R PENALTI'OF PERJURV ONE OFTHE FOLIOWIN�UECLARATIONS: � C� Q � IHAVEAN�WILLMRIN7AINACERTIFICATEOFCONSENTTOSELF-INSUREFORWGRKEPS' _ — COMPENSATION,ASPROVIDEOBYSECTION37o00FYHElRUORCODE,FORTHEPERFORMANCE 6L OFTHE WDRK FOR WMICH THIS VERMIT IS ISSUEO. � 0 _I HAVE AND WILLMAINTpIN WOpKERS'COMPENSATIDN INSURANCE,AS REQUIRED BY SECTIDN � Q37000FTHELPBORCO�E.FORTHEPERWRIA/YCEOFI'HEWORKf-0RWHICHTHISPERMITIS � ISSUEO.MY WORKEPS'COMPENSATION INSURANC[CARFIEfl AND POLICY NUMBER AflE: CONSTRUCTION _. .—�/y�.� _.._._ Ce/ _ ' _""_ _ 7 CARRIER �//MI/�+�32�/P.I� t?e�w+�-!=/,_lif�3 _ PLANREVIEW �`--- ------- zPOLICVNUMBER__L'L��a�l��',a._�,7"� _"'�� ELECTHIC ......------ --..---.— d � 0 (IHIBSECfKYJNE�NDTBECLKPLtTmOFTHEPERhSRtSFDPOAEMIN�OF7EDOq.lAR..(5100)OqLESS� PLUMBING --..----..— - Z ICERTIFYhIATINTHEPERFOflMANCEOFTHEWORKFORWHICHTHISPERMITISISSl1ED,l MECHANICAL .__ __._� _ C,'} SFIFLLNOTEMPLOYANYPERSONINANYMPNNEHSOASTOBE(:OMESUBJF.CTTOTHE � Uj WORKERS'COMPENSATIONIAWSOFCALIFOHNIA,AN�AGREETHATIFISHOULDBECOME INSPECTIONFEE _______ �' S SUBJECTTO THE WOHKEHS'COMPENSA710N PqOVI510NS OF SECTION 370o OF TH[IABOR --— -- CODE,I SHALL FORTIIW Ihl COMPLY WITH THOSE PROVISIONS. ISSUANCE i t _'""— __ p DATE: ���`ue'�V APPLICANT: A � �`�-�-�' SMIP __`. Q._ .c 7_.___ J ENERGY P/C � WAflNING.FAILURETOSECUPEYlORKEFiS'COMP SAfIONCAV[RAGEISUNLAWFUL.ANOSHALLBE —�� LL SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFMESUPTOONEHUNORGDTHOl1SAN0 ENERGYPEHMIT � �OLLARS(f 1�7.000).IN A��ITION TO THE COST C7F COMPENSATION,�AMAGES AS PNOVIUCD F�H IN ¢ SEGTION37oBOFTHELAeOPCODE,INTEREST,ANDATTORNEYSFEES. RETENTIONFEE: �� „_.________ I a CONSTRUCTION LEN�ING AGENCY pR -ALT FEE: _._....___—___, �__ U � IHEREBVAFFIRMUNDEPP[NAL7VOFPFRJURYTHATTHEREISACONSTRUCTIONLENDWGAGENCY ZFOR THE PERFORMANGE OF THE WORK FOH WHlql THIS PERMIT�S ISSUED(SEC,309],CIV.C.�. - ����� � � W --_' � LENDEWS NAME --._ _"'____' "'_""_ F- LENOER'SADDRE55__ __._.-_._..... _...__ � ICERTIfY7MATIHAVEREADTF115APPlICATIONAND3TATETHATTHEABOVEINFORMATKKJISCORRECT. ��/TALFEES � � I AGPEE TO(:OMPLV WITH ALL C(iV AND COUNTV OPDINANCES AND STATE LAWS RELATING TO A111l�ING qq CANSTRUCTION.AND HEREBY AUTHOPIZE HEPRESENTA71YF.5 OF THIS COUNTY TO ENTER UPON THE �/ �°p�J� �' QT"" _ � S� ABOVE�MEMIONED PROPERTV FORINSPECTION PURPOSES. COMMEI�TY=a��'� 1_]F�✓•�'-���`�f L������ _ O � �r��t�U t���l F__`;c� �� ` -� ---- ------ — ---- � � PEflMITTEENAMEJPRINT) � � � '_'�} ••a.,,�/�.� ' � �1J y SION U PERMITfEE DATE � _ �'' �� RECPT.NO. 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