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HomeMy WebLinkAbout17346 (23) _�� _ CITY OF DIAMOND BAR `� � DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES � 21825 E.C�piey Drive (909)860-3195 F�(909)861-3117 PRESS ""%������ UILDING PERMIT APPLICATION FIRMLY � JOBSITE � �' �/�� �j �I�� APPLICATION�!_ � , d/ PERMIT ��7 P/C o ADDRESS ✓ DATE NUMBER f�� # � ISSUE TYPE OCC APN LOT T ACT �--- DATE CONST. GROUP p OWNER -1I✓C. _ " ADDRE � ZONING SETBACKS Z CITYf ZIP_ EL. FRONT RW ❑ � APPLICANT TEL REAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTOR � _� SIDE G o ADDRES � .� . nt.�� . � PROPOSED USE CITY �✓//1 ZIP_'�� TEL. o ARCH/ENG/ �z DESIGNER NO,DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEFEeV AFFIRM UN�ER PENALiY OF PERJURY THAT I AM E%EMPT FROM THE CONTfiACTORS U� G818CJB/C2f{10f2 �W CENSELAWFORTHEFOLIOWINdREASON(SECJoa1.58USMESSAN�PROFESS10N5CODE:ANYCITYOR (n U COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IIAPROVE,DEMOLISH.ORREPAIRANYSTRUC- W PflilO/DECK Z TURE,PRIOR TO ITS ISSUANCE,AL50 REQUIPES THE APPLICAN7 FOR Sl1CH PEflMiT 70 FILE A SIGNED W W STATEMEN7 7HAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTR4CTORS ll- � CENSE LAW�CHAP7ER e(COMMENCING WITM SECTION]00�)OF�IVISION 3 OF THE BUSINESS AND PqO� � POOUSpB � FE5910N5 CADE)ORTHAT HE 9R SHE IS EXEMPT THEREFROM AN�THE 6A515 FOR THEAL:EGED EXENP- � pTION.ANYVIOLATIONOFSECTION7o31.5BVANYApPLICANTfOqAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Root ACIVII PENA�TV OF NOT MORE THAN FIVE Hl1NDRED DOLURS(E50o�.): Z ❑I,ASOWNEFOFTHEPROPERTV,ORMVEMPIOYEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 COff1fT10fCIdI WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEG.7044,BU51� J NESS AN�PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTYWHOBUIL�SORIMPROVESTHEREON,ANDWHODOESSUC}1WORKHIMSELFORHERSELFOR = � iHROUGHHI50RHEROWNEMPLOYEES.PPOViDEDTMATSUCHIMVROVEMENTSARENOTINTEN�EDOR m QOFFEREDFORSAIE.IF,HOWEVER,THEBUILDINGORiMPROVEMENTISSOLDWfTNINONEYEAROFCOMPLE- Z TION,7HE OWNEfi-9UILOER WILL HAVE THE BURDEN OF PROYING TFIAi HE OR SHE DID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SALE�. W ❑I,ASOWNEROFTHEPqOPERTY,AAAEXCLUSNELVCONTRACTINGWffHLICENSEDCONTRACTORS � TO CONS7RUCT THE PFOJECT ISEC.�o4d,BUSME53 qND PROFESSIONS COOE:THE CONTRACTORS LI- V21U3IIOf1 ADJ.AREA W CENSEIAWDOESNOTAPPLV70ANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND � WHOCOMRACTSFORSUCHPRQIECTSWITHACONTRACTOR(57LICENSE�PUFSUANTTOiHECONTqAC- Q(JANTITV DESCRIPTION FEE Y TORSLICENSELAW.). A ' .�r� � ❑I AM EXEMPT UNDER SEC. B.&P.C.FOP THIS REASON U y' �• �P../ � / � F 7 OATE OWNER U Z W � LICENSED CONTRACTORS OECLARATION W Q � 1 HEREBV AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNOER PROVISIONS Of CHAPTER � d 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PPOFESSIONS GODE,AND Z W MY LICENSE IS IN FULL FORCE AND EF�FEC�T,.f /1 m � LICENSE � / LIC.NO, �/ D j 4- U OATE Z CONTRACTOR � � d W a� WORKERS'COMPENSATION DECLARAT N Q � U � 1 HEREBV AFFIRM UNDER PENALTV OF OERJURY ONE OF THE FOLLOW'�NG DECLARATIOI:�S f!J a � IHAVEANOWILLMAINTAINACEqTIFICATEOFCONSENTTOSELF�NSUREFORWORKERS' _ MPENSATION,AS PROVIDED BV SECTION 37o00FTHE LABOR CODE,FOR THE PERFORMANCE U a OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED. � � W I HAYE AND WILL MAMTAIN WORNERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION Q 3�OOOF THE LABOR CODE,FOR 7HE PERFpRMANCE OF THE WORK GOR WHICH THIS PERIAIT I5 ISSLIW.MVWORKERS'COMPENSATIO RANC CARRIEAANDPOLICYNUM6ERARE: CONSTRUCTION � CARRIEP ��'Ti� Cltir PLAN REVIEW �t� 0 PoucvNUMaER_��r��� ELECTRIC 1 d� r �–^�-p ¢ � ('.NISSECTpNNE�NOTBE00MPI.ETEDOFT�EPERMfTIS�ORONEHUNDR[DDJILARS(S1W�OfiLESS�. PLUMBING Z ICERTIFVTHATINTHEPERFOR . RWHICXTHISPERMITISISSUE0.1 MECHANICAL ��� -"�-"' ��'-'�-"` (} SHALLNOTEMPLOVANYPER INA' MANNEFSOAS BECOMESUB�ECTTOTH[ �[.._..,.,Ji ,/� �� � R I FTufJ WORHE 'CO 7ENSA'ION WSOF ALIGO IAANDAC EETHATIFISHOUL�6EC0 INSPEC710NFEE r°� SUBJEC TO EWORHER COMPE SA'ION R I51 N OFSECTION3�ooOFTH OR N � COOE, Hq FOR7HWRH OMpLY ITH VI ONS: ISSUANCE •�� • � p DATE � � APPLICAN SM{P � W ENERGY P/C J WARNING:F ILURETOSECUREWORKERS'COM7ENSATIONCOVERAGEISUNLAWFl1L,AM1DSHALLBE J W SUBJECTANEMPLOYERTOCFIMINALPENALTIESANOCIVILFINESUPTDONEHUNDREDTHOUSAND ENERGYPERMIT `l:5'iC.ro DOLLARS�Sfoo,o0o),INADDITIONTOTHECOSTOFCOMPENSATION,DAAAAGESASVROVIDEOFORIN - . JSECTION3]080FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. e•'�"�.�'M����,���":���y� � RE?ENTION FEE: "` -"' � �� � f • L�� d CONSTflUCTION LENDING AGENCV PRE-ALT FEE: O � IHERE6VAFFIRNUNDERPE�ALTVOFPERJURYTHATTHEREISAGONSTRJCTIONLENDINGAGENCV FOR TNE PEFFORMANCE OF TNE WOPK FOR WHICH THIS PERMIi IS ISSUED(SEC.30W,CIV.C.). Z W � IENDER'S NAME F_- LENDER'SA��RESS W ICERTIFYTHAT VEREADTNISAPPLICATIONANOSTATETHATTHEABOVEMFORMATION�SCORRECT. TOTAL FEES � ��d � IAGREETO P� W�THPLICRYANDCOUNTVORDINANCESANDSTATEL4W5RELA7WGTOBUILDING ,� WNSTRU IONAI��HEREBYAUTNORREREPRESENTATIVcSOFTHISCOUVTYTOENTERUPONTHE Z ABOVE- NTIO SPECTION PURP COMMENTS � � J � � QPERMITTEE A (PRINT �/� 4 � � i � SIGNATVREOFP M �� DATE = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR D—File Copy,GREEN—ApplicanYs Copy . , , , .. �, _ . -- . , , �.. , � � • � . . . ., ..'�.�,� ..... �� ,...:...� ,..r' .T;; .�.-..�... ..��.,��;. . ., ... .' r w'. .�.� . 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