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HomeMy WebLinkAbout17306 CITY OF DIAMOND BAR - �t`�� DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES -"""�°"-�"°� I,w„� � 21825 E.Copley Drive -^'"�.��°"'��� � (909)�60-3195 Faac(909)861-3117 .`��� PRESS �%yN°� BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE �� �� '1%����� � �j ,ptl pppLICATION PERMIT p/C Q ADDRESS_ �� T���y' � o DATE NUMBER # :-° APN LOT TRACT ISSUE p TYPE OCC p OWNER 2��- DATE ^� CONST. GROUP p ADDRESS � ZONING SETBACKS z CIT���1C� ZIP EL FRONT RW G o APPLICANT TEL. REAR � Z SIDE/SIDE STREET Ry�/ ❑ Q CONTRACTOR S�- f�D SIDE � ADDRE55 � CITY �NTA�5�7�2.1 tl IP PROPOSED USE .�_f�,Q �'T'EL. o ARCH/ENG/ z DESIGNER � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. STORIES BEDROOMS '� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAIVALUATION p� � OWNER-BUILDEF DECLARATION p SFR/ADDIREM p I HEREBY AFFIRM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE CONTPACTORS LI- G8f298/C2fp01t W CENSELAWFORTHEFOIIOWINGREP.SON(SEC.7031.SBUSINESSANDPflOFESSIONSCO�E:ANYCITYOR (n � COUNTVWHICHREQUIqESAPERMITTOGONSTRJCT,ALTER,IMPROVE,OEMOIISH,ORREPAIRANYSTRUC- W P0f10/DeCI( w TURE,PRIOR 70ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPiER 9(COMMENCWG WITH SECTION 70D0)OF ONISIpN 3 0F THE Bl1SINESS AND PRO- � POOUSPfl � FESSIONSCADE)ORTHATHEORSHEISEREMPTTHeREFROMANDTHEBASiSFOR7HEALlEGEDEXEMP- (� V TION.ANYVIOLA?IONOFSECTION7a31.58YANYAPPLICAN7FORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof A CML PENALTV OF NOT MORE THqN FIVE HUNDRED DOLLARS(S600).�: � ❑I,ASOWNEROFTHEGROPERTV,OFMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfflffl0fC18I Z WILL00 TNE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.1D4q,B�51- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTV WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HEFSELF OR � THROUGHHISORHEROWNEMPIOVEES,PFOVIDEDTHATSUCHIMPROVEMENTSAPENOTINTENOEDOR m 0 oFFEREDFORSALE.IF,HOWEVEF,THEBUILOINGORIMPqOVEMENTISSOLDWITHINONEYEAROFCOMPLE� � TION,THE OWNER�BUILOER WILL HAVE THE BUR�EN OF PROVMG TI1AT HE OR SHE OID NOT Bl11LD OR = IMPROYE FOR THE PURPOSE OF SALE). w ❑I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING VJITH l IC[NSED CON7RACTORS � TO CANSTRUC7 THE PROJECT(SEC.�o4A,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS ll- vaIU2i10/1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANONMEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND = WHOCONTRACTSFORSUCHPROJECTSWITHACONTPACTOR�SjLICENSEDPVRSUANTTOTHECONTRAG FEE ~ TORSLICENSELAW.). QUANTITY DESCRIPT�ON Y � OIAME%EMPTUNDERSEC. 9.&P.C.FORTHISREASON Q � U u' �ATE ONMER � Z U � LICENSED CONTRACTORS DECLARATION W � 1 HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9(COMMENpNGWITHSECTION700oJOF01VISION30FTHE8l1SINESSANDPROFE55lONSCODE,AND Z 'X MV UCENSE IS IN FULL FORCE AN�EFFECT. m � L�CENSE �SS �^ LIC.NO, � � U �ATE d , CONTRACTO d W � WORKERS'COMPENSATION DECLARATION ¢ � D ��� � IHEFiEBYAFFIRMUNDERPENALTYOFPERJ�RVONEOFTHEGOLLOWINGOECLARATIONS � � Z 0 _IHAVEANDWILLMAIN7AINACERTIFICATEOFCONSEMTOSELF-INSUREFORWORKERS' a Z = Q CAMPENSATION.ASPROVIDEDBYSECTION370aOFTHEIABORCODE,FORTHEPERFORMANCE U Q OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED. � � �I HAVE AfiD WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIREO BY SECTION � 3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI7IS J ISSUE�.lAYWORKEFS'COMPENSATIONINSsU�RANCECAP,R�IEFaANDP_OiLICYNUMBERARE: CONSTRUCTION � CARRIER S�hyT���'aCA�"'� �^I�� {� �MS y�/1�tl�7 p�qN REVIEW z Pa.ICY NUMBER 41y `�J '� ELECTRIC ¢ � (IHISSECTKKJN'cmNOTBECOMPLEfEDOFTiEPEPMfTISFORONEHUrOREDWlLMS(E1W)ORLESS). PLUMBING Z �CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAI �� � SH0.LLNOTF.MPLOYANYPERSONINANYMANNERSOAST 9ECOMESUBJECTTOTHE (J� WOfiKERS'COMPENSATIONLAWSOFCALIFCRNIA,AN�AG T TIFISHOULOBECOME INSPECTIONFEE = SUBJECTT07HEWORNERS'COMPENSATIO VISIONS E O o0 EUBOR r..�.,. CO�E,I HAILF fiTHWITHCOMPLVWITHT PROVISIO . ISSUANCE � [� � p OATE: t� � "`I APPLICANT: - SMIP W J WARNWG FPJLURETO SECUFE WORKERS'COMPENSATIDN VERAGE IS UNL4WFUL.ANO SHALL BE ENERGY P1C �y StIBJECTANEMPLOYERTOCRIMINALOENAITiESANDCIVILFINESU7TOONEHUNDPEDTHOUSAND ENERGYPERMIT OOLIARS(St 00.0001,IN AODITION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN J SECTION 3]oe OF THE IABOP CODE,INTEREST.AND ATTORNEV'S FEES. � W RETENTION FEE: O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HERE9V AFFIRM UNOER PENAITV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED(SEC.3oB],CIV.C.). Z W � LENDER'S NAME 1— IENDER'SADDRESS � TOTAL FEES q� � "'�- � ICEflTIFYTHATIHAVEREA�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. w 1 AGPEE TO�biPlY WITH ALL CITV AN�COUNTV ORDINANCES AND STATE LAWS RElAT1NG TO BUILDING � � CONSTRUCTION,ANO HEREBV AUTHORRE REPRcSENTATIVES OF'HIS COUNTY TO ENTER UPON THE � ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. Z � i � ��M��� COMMENTS � � w c�� = y,,.�{y�ac_. m PERMI NAME(PRI ,/p ¢ 'es9 �� a C/� � � NA O PERMITTE DA E � RECPT.NO. 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