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HomeMy WebLinkAbout10089 � . , s CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT �,.� 216b0 E.Copley Drive Suite 190 PRESS (909)860.3195 Fax(909)861-3117 � ""'� BUILDINGPERMITAPPLICATION FIRMLY QJOBSITE �� ,ja/y {"�7, DATECATIO� I��' . NUMBER �` � C #,C a ADDRESS. � Z ZC� ��'M � E,u��� It � � ISSUE TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER J � � ADDRES __ [��� iJ•- F�1/�R'�/./L�fea.�.�Yi ZONING SETBACKS � w r� ... FRONT RW ❑ � Z CITY p�j�F!ICJ/� ZIP �I �� TEL. 7 j 1 /� g APPLICANT ���{!4-j(�Y..l Gp TEL. �— � SIDE/SIDE STREET � '.i .T�1�— p � z � CONTRACTOR . s R-', SIDE ❑ E O CDDRESS �ZIP TEL' PROPOSED USE l^ '� '� e.• 6' i w ARCH/ENG/ t' �� � z DESIGNER W NO.DWEL. NO. NO. n. ADDRESS UNITS STORIES BEDROOMS � � C�TY ZiP TEL.---L-- u> DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ! � OWNER-6l:ILDER�ECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENAITY OF PERJURV THAT�AM EXEMPT FROM THE CONTRACTOR5 LI� GBfa /Ca OA € W CENSELAWFOFlTHEFOLLOWINOREASON(SEC.7031.58USINESSANOPHOFESSIONSCO[IE,ANVCITVOR (f� � � [ U Cp�JryTYWHICHREWIflESAPEflMITTOCON5TRt1CT,ALTER,IMPROVE,DEMOLI5H2OqqEPAIRANYSTRUC- W Patio/Dack w TURE,PRIOR TO ITS ISSUANCE,AL50 qE�U1RG5 THE MPUCANT FOP SUCH PEqM1T TO FILE A SIGNED W � � STATEMENT THAT ME OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF 7ME CONTMCTORS�I- � � � CENSE lAW(CHAPTER B(CAMMENCING wI7H SECTION 7000)Of DIVISION 30F THE BUSINESS AND PRO- POOUSp4 � FESSION5 CODE)OR THATHE OR SME IS E%EMPT THEPEFHOM AND 7NE BASIS FOR THE ALLEGED EXEMP- TION.ANYVIOIATIONOFSEC110N703t.5BVANVAPPLICANTFORpPERMITSU&IECTSTHEAPPLICANiTp Z Re•Roaf � A CIVIL PENPLTY OF NOT MORE TNAN FNE HUNDflED DOLlARS(f5u0)): � zL]I.ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWq0ESA5THEIRSOLECAMPENSATION, ❑ COIIlRI0fC181 � WILl00 iHE WOqIS.PND TNE STRUCT11qF IS NOT INTENDEO OR OFFERE�FOR SALE(SEC.704C.BU51� J � NE55 AND PROFE6SIONS CADE:THE CONTRACTORS IICEMSE UW DOES NOT APPLV TO AN OWNER OF j I , PflOPERTY WHO 9URA5 OR IMPROVLS THEREON,MD WFIO DOES SUCH WORK HIMSELF OH HERSELF OR ' � THROUGHHISORHEROWNEMPtOYEES,PROVI�EDTHATSUCHIMPpOVEMENTSAREhOTINTENDEDOp m � W OFFEREUFORSN.E.IF,MOWEVERTHEBUIIDINGORIMPROVEMENT1550lDWITHINONEYEFflOFCOMPLE- 0 TIDN,?HE OWNEq-BUIIDER WILL HAVE THE BURDEN OF PqOVING THAT HE OR 6HE DID NDT DUIID OR ' � IMPROVE FOR THE PIIRPOSE OF SALE). � ❑I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRAC7ING WITH LICENSEO CONTMCTORS i Q TO CONSTRUCT iHE PR0.IECT(SEC.�OdO,BUSINE55 ANO PROFESSIONS CODE:7HE CONTflFCTOR5 LI� V21U3fi0R ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILD60RIA1PROVESTHEflEON,AND i � WMOCONTRACTSFORSUCHPRDJECTSWIT}1ACONTRACTOq�S)LICENSEDPURSUANTTOTNECONTHAG QUANTITV DESCRIPTION FEE � � 70RS LiCENSE LAW.). � � ❑I AM EXEMPT UNDER SEC.____ __„ _B.fl P.C.FOH THIS REASON Q � � U '- ---- ---- �-------�----- ¢ LL DATE _OWNEFl F' ` Z � LICENSED CONTRACTORS DECLARATION ^ W � � I HEREBV AFFIRM UNDER PENAITY OF PERIURY THAT IAM LICENSED UNDEfl PROVISIONS OF CHAViER �y d 9(CUMMENCING WITH SECTION 70007 0F OIVISION 90F 7HE BUSINESSANO PHOFESSIONS CODE,AND Z �� 'g; � w MY LICENSE IS IN FULL FORCEAND EFFECT. m /� ���,y-- ]��![,� i � IICENSE CLrAqSS l.. �Y] _ LIC.NO._ �L1S_V��l � i W �A7E Y^` � ��,__ CONTRACTOR �F8 a h� r� e i � WORKERS'COMPENSATIONDECLARATION —� ' • ' �`' ; � �°��r� � � � IHEREBYAFFIRMIJNDERPENALTYOFPERIURVONEOFTHEFOLLOWIN6DECURATIONS: j 0 ._INAVEANDWILLMA�NTAINACERTIFICA7EOFCONSENT70SELFJNSUREFOHWOHKERS' _ � 4 COMPENSATIDN,ASPROVIDEDBYSECTION3�ooOFTH[LA90RCODE,FORTHEPERFORMFWC U Q OF THE WORN iOR WHICH THIS PEFMIT IS ISSUE�, w � � ' � 1 W _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSUPANCE,ASREOUIREDBVSECTION � Q 37000F THE LABOR CODE,FOR THE PERFOFMIINCE OF THE WORK FOR WHICH THIS PERMRIS /` ,/')�, � ISSUED.MY WORKERS'COMPENSATION IN9UFiANCE CARRIEfl AND POLICV NUMBEHARE: CONSTRUCTION ��/ � 4 V J " � � CARRIER `• `�. _�� y'- � � PLAN REVIEW � ' IrU € Z POLICVNUMBER �S9_�'�P-. LT .5�... . � r. @LECTRIC ¢ 0 (IFIISSF.GIIIXJNE�NOTBEWMPIEfFDOFh1EPERNRISFORON�MA�DHHED00.LPR5[b1 o�Ess�. PLUMBING � Z I CERTIiY THAT IN THE PERFORMANCE OF THE WOflK FOR WHICH TNIS PFRMIT IS ISSl1EU.I MECHANICAI j (�} SHALLNOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BEC041E SU&IECT TOiHE � WORKEflS'COAIPENSATIONLAWSOFCALIFORNIA,ANDA6REETNATIFISHOULD�ECOME INSPECTIONFEE � SU&IECT TO TNE WORKF:A9'CAMPENSATION PHOVISIONS OF S[CTION 3700 OF THE LABOR - � ' { � CA�E,1 SHALL FORTHWITH COMVLV WITHTHOSE PRWISIONS. ISSUANCE � /'��� � p OATE: _ APPLICANT: _�____ SMIP - Vjli ,_ p W �-- i J WARNIN(i:FAILURE TO SECURE WORKEH6'COMPENSATION COVERRGE IS UNLAWFUL,AN�SHALL 8E ENERGY P!C � SU&IECTANEMPIOYERTOCRIMINALP[NALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � OOLLARS(5100.000).IN ADOITION TO THE COST OF COMPENSATION,OAMhGES AS PROVIDED FOR IN � SECTION370BOFTHEUBORCODE,INTEREST.ANDATTORNEV'&FEES. RETENTIONFEE: � ._ ��J � � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � � I HEREBV AFFINM UNDEP PENALTY OF PERJl1RY THAT THERE IS ACANSTRUCTION LENDING AG[NCV ' � � fOR THE PERFORMANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUED�SEC.3097,CIV.C.�, `---- F Z I w � LENOER'9NAME__ _ _ _ F- LENDEF'SA��RE55 .__._ _,_ � ICERTIFYTHATIHpVEflEADTHISAPPI�ICATIONAN�STATEhiATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � W IA6HEETOCOMPLYWITriALLCffYANDCOUNTYORDINANCESANDSTATEIAWSpELATINGTOBUILOMG F � CANSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCAUNTYTOEN7ERUPONThIE F Z ABOVE-MENTIONED PROPERN FOR INSPECTION PURPOSES. � Q COMMENTS_____ � �'•'�F-P i.1 �°(� - aPERMITTEENAME(PRIM) ____ j � € N SIGNANHEOFPE EE D TE �y R = RECPT.N0. 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