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HomeMy WebLinkAbout10440 (5) -•"• CITY OF DIAMOND BAR , � COMMUNTTY DEVELOPMENT DEPARTMENT .;,.r; 21660 E.Copley Drive Suite 190 !%��` PRESS (909)86a3195 Fax(909)861-3117 �'""' BUILDINGPERMiTAPPLICATION ' FIRMLY o� JOBSITE f,��� ,� e�y�tf�e f� ��� /,/�u APPLICATION� �� `n PEFIMIT ��L�/�f� Pl ��` ADDRESS ��'' « O !� DATE NUMBER f��� J ISSUE TYPE OCC � � ��/�"� APN LOT TRACT DATE �_ CaNST. GROUP p OWNEH " ADDRESS ZONING SETBACKS oCITY ZIP TEL. FRONT RW 17 � APPLICANT TEL. REAR ❑ � „ SIDE/SIDE STREET RW ❑ � CONTRACTOR ` � E"� . '�/�-� `•` SIDE ❑ ADDRESS ")O !J•c.- -� i .S 7 L/�' s, � � CITY /�/1 FJl4� y�`� ZIP O%�° TELf3'i��'j�'";1� PROPOSED USE �~�- ��/��� I w ARCH/ENG/ ( z DESIGNER NO.DWEL. ., NO. NO. a ADDRESS UNITS " 3TORIES BEDROOMS � � CITY ZIP TEL. c�» DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BI:ILDER DECLARATION SFR/ADD/REM O Z � I HEREBY AFFIRM UNDER PENALTV OF DERJURV THAT I AM EXEMPT FROM THE CONTMCTO0.S L6 � G8f8Q6/CBfpOR f W CENSEUWFORiHEFOLLOWINOREASON(SEC.7037.5B1151NESSANDPROFES810N9CO�E:ANYCITYOR C] COUNTVWHICHqEOUIHESACERAI�TTOCONS7RUCT.ALTER,IMPROVE,�EMOIJSH,ORREPAiPANVSTRUC• W pg110/DBCk Z 7URE.PRIOH TO IT3198UAMCE,AL50 REWIRES THE APPLICAM FOH 5UCH PERMIT TO FlLE A SIGNED W ' � STATEMENT THAT HE OR SHE IS LACENSED PURSUANT TO THE PNOVISIONS OF THE C�NTMCTORS LI- LL � � CENSE LAW�CHqPTER 8(COMMENCINO WITH SECTKKJ 7000)OF DNI910N 90F THE BV9INESS MID VR0- POOVSPB � FESSIONSCODE)ORTHA7HEORSXEISE%BMPT7HEREFqOA1pNOTMEBA313FOR7HEALLEOEDE%EMP- (� " VTION.ANYVIqA710NOF5ECTION7o31.5BYANYAPPLICANTFORpPERMITSUBJEGT5IHEAPPLICMITTO Z Re-Raoi � A CIVIL 7ENALTV OF NOT MORE TNAN FIVE HUNONED�OL(ARS(SSOD�J: � �� F � ❑I,ASOWNEFOFTHEPROPERiY,ORMYEMPLOVEESWITHWRGE5A5TXE1flSOLECOMPENSATKKV, 0 N1ILL DO THE WOAN,PND THE STRUCiURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.7o4t,BUSI- J Comme�cial � � NE55 AND PHOFESSIONS CODE:7HE CON7RACTORS UCENSE LAW DOES NOTAPPLY TO AN OWNER OF � ; PROPERTVVhiOBURA50RIMPROVESTHEREON,PNDWHODDESSUCMWORKHIMSELFORHEfi4ELFOR m j � TMROUGMHISORHEROWNEMPIOYEES,PROVIDED7HAT5UCMIMPROYEMENTSARENOTINTENDEDON i OOFFEHEDFORSALE.IF,HOWEVERTHEBUILDINOORIMPROVEAIENTISSOL�WITHINONEVEANOFCOAIPLE- i Z TKKJ,iHE OWNEH�BUIIAER WILL HAVE itlE BURDEN Of PROVING THAT HE Oq SHE DI�NDi BUIID OR { � IMPROVE FORTHE PUPPOSE OF SALEJ. € W ❑I,ASOWNEROFTMEPROPERTY,AME%CLUSIVELYGON7RPCTINGVAiHIILENSEDCONTMCTORS � � TO CONSTRUCT THE PR0.IECT(SEC.70U,BUSINESS AN�PROFESS�ONS CODE:7NE CONTMCTOpB U- V8W011011 �� ADJ.AREA W CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEflEON,AND � NMOCONTRAC75FORSUCHPROJECTSWI7HRCONTMC70q�5�UCENSEDDUpSUN4TTOTHECONTpAC- QUANTITY DESCRIPTION FEE TORS IiCENSE LAW.�. �A J ¢ O I AM EXEMPT UNDERSEC. B.8 P.C.FOP THiS REASON U s/�S�� / C��� S ��"`+., � � r'...X.'3 �a't,s c%�t_�A� �� i DATE �OWNEH___ Z W Y � UCENSEDCONTRACTORSDECLARATION , W f � 1 HEREBYAFfIRM UNOER PENALTY OF PERIURY THAT IAM LICENSED UNDEH PHOVISIONS OFCNAPTER � C �u� �� G• d 9(COMMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,AND Z -� ', X MY LICENSE I51N FULL FOflCEANO EFFECT. � � � ' � � � / [l.0 L-�+-�- � IICENSE CLASS�_LIC.No. �f ���r� � j �'� E J �l''�f'� k / ! ��r �� 3 V DATE—� �i(v "�� � COMMCTOR�!"li 0 A L.�C�sC.t9i1 � � G�✓- " �/cs'+'T�'✓'cr S• �� W � WORKEFiS'COMPENSATIONDECLARATION U � ^�u,� � J .C�.£.-B�:.a �• � �• � 1 HEREBYAFfIRM 11NDER PENAITY OF PE0.IURY ONE OFTME FOLLOWING�ECIARAT10N5: z � Q � O IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEMTOSELF-INSUREFORWORKEflS' 2 I• � PENSATION,ASPROVIDEDBYSECTION37000FTHELABORCODE,FORTHEPERFORMANGE W � OF THE WORK FOR WHICFi THIS PERMIT IS IS9UED. �--- � • �^• � W _IHAVEANDWILLMRWTAINWOpKERS'COMPEN9ATIONINSUMNCE,ASREQUINEDBVSECTION �1�� {�O � Q 37000FTHELABORCO�E,FORTHEPERFORMANCEOFTNEWORKFOqWHICHTHISPEMIITIS 3� '�" ISSUED.MY WORKERS'COMPENSATION INSUHIWCE CARRIEfl AND POLICYNUMBEPME: CONSTRUCTI N t� �� �' j cnaniEp__ J� _�'��°•�.� PLAN VIEW f� V S� "�Gt'J`.? �U C .a�✓�.7c> �� � � POLICY NUMBER /�� '�"s^5�L�G� ELECTRI ' � ¢ f Q 0 (RAssEciqNNE�NOTBEaoM�LEfEuaFn+EPEHMrISfORat+Etll.P�DRmoOLLnFiS(s1W)oHt.ESS} PLUMBIN / //• Z 1 CEflTIFYTHAT IN THE PERFOPMANCE OF THE FOH ICH THIS PERAIIT IS ISSUEO.I MECHANICAL (.�} SHpLL�TEAIPLOYANYPER50NINANYMMI SOAST BECAMESUBJECTTOTHE � WORKEq3'COMPENSATION UWS OF CALIFO IA,AND REETHAT IF I SHOULD BECOME INSPECTION FEE ? SU&IECTTOTHEWORKERS'CAMPENSAT PROVIS SOFSECTION37000FTHELABOq V �-�/ CODE,I SMAIL FORTHWITH COMP WiT HOSE P ISIONS, ISSUANCE / o C sM �'" `� 3S• ?° p �ATE� APPLICA . ' j---- . . � Y P/C _ '� � � WARNINO:FAILURETOSECUREWYfRKERS'COMPENSA71ONCOVE A6EISUNIAWFUL.ANUSHALLBE � �y SUBJECTANEMPLOYERTOCRIMWhLPENALTIEBANUCIVILFINESUPTOONEHUNDREDTNWSANp ENERGYPERMIT OOLURS(5700,000),IN ADDITION TO THE COST OF CAMPEN5ATION,DAMAGES AS PROVUED FOR IN q +J � SECTIDN37080FTHELABORCODE.PITERE57,M1DATTOqNEY'SFEES. ENTION ylsa� dOli 'r'6 fG'1Wl� /I�_I d CONSTRUCTION LENDING AGENCY �� � ' PRE-ALT FEE: O � IHEFEBYAFFIRMUNDERPENALTYOFPERIURYTHATTHEREISACONSTRUCTIONLENOINGAGENCV r� FOR TME PER WFMANCE OF THE W�RK FOR WHIGH TMIS PERMIT IS ISSUED(SEC.7097.CIV.C.). 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