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HomeMy WebLinkAbout17439 (26) �,�-— CTTY OF DIAMOND BAR �I I � � n'�P�T��TT OF COMMUNITY&DEVELOPMENT SERVICES � ; .�,,� 21 S'LS E.Capley Drive (909)860-3195 Fax(909)861-3117 PRESS "''-�����' $UII.I>INGPEd3MI'�APPLICATION FIRMLY JOBSITE APPLICATION I ERMIT P/C o ADDRESS��� � ��� s�.'�_ � � DATE `� � UMBER�� # o� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP � OWNER��� ��I�c� (,,.a 1�-� O ADD ZONWG SETBACKS Z CITY � ZIP EL FRONT FiW ❑ � APPLI ANT TEL. REAR ❑ � SIDE/SIDE STREET RW � z - ¢ CONTRACTOR ` SIDE ❑ ADDR � � CITY ZI TEL. PROPOSED USE `^' R Q ARCHlENG/ � ��� �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDRaOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUA710N - � OWNER-BUILDER�ECLARATION SFR/ADD/REM � O � I HEREBY AGFIRM UNDEF PENALTV OF PERJURV THAT 1 AM EXEMP?FROM THE CONTRACTOqS L6 Gdfd9E/C3fPOfI W CENSELAWFORTHEFOLLOWINOREASON(SEC.7031.50USWESSANDPROFESSIONSCODE:ANYCIiYOR (n U fAUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,NLTER,IMPflOVE.DEMOLISH,OflflEPAIRANYSTRUG W Patio/Deck W TURE,PRIOR TO ITS ISSUANCE,AL50 FjEQUIRES iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNFD w STATEMENT THAT HE OR SHE IS UCENSE�PURSUANT i0 THE PROVISIONS OF THE CONTRACTORS L�- � CENSE LAW(CHAPTER 9(COMMENCING'�WITH SECTION 7000)OF OIVISION 3 OF THE BUSWESS AN�PRO� � POOVSpB FESSIONSCO�EjORTHATHEORSHEI9��,EXEMPTTHEREFROMANDTHEBA515FORTHEALLEGEDEXEMP� (� � TION.ANYVIOLATIONOFSECTION7031.56YANYAPPLICANTFORAPERMITSUBJECTSiHEAPPLICANTTO z Re-Roof � A CIVILPENALTY OF NOT MORE THAN FIVE HUNDRED�OLIARS(5500).�: Q ❑I,ASOWNEROFTHEPROPER7Y,ORMYFMPLDYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CqmmefClel - Z WILL DO THE WORK,AND THE STRUCT17RE IS NOT INTENDE�OR OFFERED FOR SALE(S6C.7C44,BU51- J NESS AND PROFESSIONS CODE:THE CONTflACTORS LICENSE LAW DOES NOT APPLV TO AN OWNEfl OF � � PROPERTYWHOBUILOSORIMPROVESYHEREON,AN�WHO�OESSUCHWORKHIMSELF�RHERSELFOR � ' � THPAUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPqOVEMENTSARENOTINTENDEDOR m ' w OFFEREOFORSALE.IF,HOWEVER,7HEBLllLDINGORIMPROVEMENTI550LOWITHINONEYEAROFCOMPLE ZflON,THE OWNER�BUIL�ER WILL HAVE THE Bl1RDEN OF PROVMG THAT HE OR SHE�ID NOT BUILO OR = IMPROVEFOR7HEPURPOSEOFSALE).;' ❑I,AS OWNEfl OF THE PROPERTY,AM EXCLUSI4ELY CONTRACi1NG WITH UCENSED CONTRACTORS � ' TD CONSTRUCT THE PR0.IECT(SEC.70A4,BUSINESS AND PROFESSIONS COOE:THE CONTRACTORS LI- V31U8tI0fl ADJ.AREA W CENSE LAW ODES NOTAPPLY TOAN OWNEfl OFA PROPERTY WHO BUIIDS OR IMPROVES 7HEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTMCTOR(SjLICENSmPURSUANiTOTNECONiRAG QUANTITY �ESCRIPTION FEE � TORS UCENSE LAW.j. � ❑IAM EXEMPT UNDER SEC. � B.8 P.C.FOR THIS REASON Q � U . ti � OATE ,,OWNER U Z W � LICENSED CONTRACTORS DECLARATION W � Q � I HEAEBY AFFIRM UN�ER PENALTV OF PERJUflY THAT I AM LICENSE�UNDER PROVISIONS OF CHAPTER � ' p„ 9(GOMMENCMG WI7H SECTION 7o00J OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE N Z 'X MY LICENSE IS IN Fl1LL FORCEAND EFFF�CT. � � m O > �(}� 6 � LICENSE CLASS LIC.NO. �+�'� ! � V DATE � CONTfiACTOR a W { � WORKERS'COMPENSATION DECLA 0 � J � Q � U � I HEREBYAFFlRM UNDEfl PENALTY OF PERJURV ONE OF THE FOLLOWMG�EGLARATIONS; Z Q � I HAYE AN�WILL MPINTAIN ACERTIFICATE OF CONSENT TO SELF-INSU9E FOfl WORKERS' _ �� COMPENSATION,AS PROVIDE�BY SECTION 3700OF 7HE IABOR CODE,FOq THE PERFORMANCE U OF THE WORK FOR WHICH TMIS PERMI7 15155UED. � 0 W _IHAVEAN�WILLMAINiAINWORKERS'COMPENSATONINSURANCE,ASREQUIRED6YSECTION Q 37ooOFTHELABORCODE,FOflTHEPEPFOPMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY KEaRpS�'C�OMPENS INSU NCECA IERANOPOLICY eRnae: CONSTRUCTION 7 CARRIER �—'"� ''��� PLAN REVIEW � � o PoucrrvurneeR ELECTRIC Z Q � (iHISSECTIQYNEmNOiBEO]UPL.EfE�OFhiEPERMRISWRONEHt1NDRm�OL1ARS(5100)ORLESS). PLUMBING Z ICERTIFYTHATINTHEPERFORt�MAM10EOFTHEWORKFORWHICHTHiSPERMITISISSU'c�,l MECHANICAL -� (�5 SHALL NOT EMPLOYANY PERSO�J IN ANY MANNEF 50 AS TO BECOME SUBJECT TO THE 't�R T p� WORKERS'COMPENSATIONLAWSOFCALIFOPNIA,ANDAGREETHATIFISHWL�9ECOME INSPECTIONFEE • �� �48 � SUBJECTTOTHEWORKERS'CO�AAPENSAiIONPROVI510NSOF5ECTqN3)ODOFTHELABOR � CO�E,I SHALL FOR�!IiHCOMPLY WITHTH SE PROVIS��NS. ISSUANCE � (� p SMIP p DATE; � y APPLIGANT. p� w ENERGY P/C J WARNINGFAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNVIWFUL,ANDSHALLBE �' �—y SLIBJECTANEMPLOYERTOCRIMI�ALP�NALTIESANOCIVILFMESUPTOONEHUNDREOTHOJSAND ENERGYPERMIT � D�LLARS(StoO,000),IN ADDITIONTOTHk COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 3708�F THE LABOfi CODE.IMiREST,ANOATTORNEYS FEES. RETENTION FEE: d CONSTR,UCTION LENDING AGENCY PRE-ALT FEE: � 1HEREBVAFFIRIAUNOEflPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLEN0INGAGENC7 .�.'Y'��� � FCRTHEPERFORMANCEOFTHEWOFKKORWHICHTHISPERMITISISSUED(SEC_3a9],CIV.C). 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