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HomeMy WebLinkAbout12243 (11) CITY OF DIAMOND BAR -- J�� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES /�� � 21660 E.Copley Drive Suite 190 � �,,� (909)860-3195 Fax(909)861-3117 PRESS I ���'A�'�.� BUILDING PERMTI'APPLICATION FIRMLY i � JOBSITE � APPLICATION PERMIT /1 P/C p o ADDRESS �� n[�4�I.�D R.�2 P�LVb �_ '62 � �C9 '-��� �J ;, DATE B^l3- NUMBER # � APN LOT TRACT ISSUE TYPE OCC DATE ��� CONST. GROUP p OWNER �,� TrtE� 1 Tp.w1ES p ADDRESS_�9� ��,6Nto►SD f36.CL t?,L� ZONING SETBpCKS Z CITY DIAMOI�D FRONT RW I.l �_ ZIP�17./� TEL.$�f O•'?�$�S REAR ❑ g APPLICANT LG�t2�� �iL�rl TEL. � SIDFJSI�E STREET RW U._�__ CONTRACTOR SIDE ❑ �,; ADDRESS � ClTY ZIP TEL. PROPOSED USE��,�a,,,y[� G t�'('�CZ W ARCWENG/ T-� I��PA�1�t'� T ( nn�FT ( z DESIGNER w NO.DWEL. NO. NO. I a, ADDRESS ��: CITY ZIP TEL. �N17S_ STDRIES rL BEDROOMS cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION . � OWNER-BUILDER DECUIRATION SFR/ADDiREM � O � 1 HEREBY AFFlRM UNOER PENALT'OF DERtt1RV THAT I qA/EXEMPT FROM THE CONTRACTORS ll- G8f2gB/C2fP011 £ W� CENSEUWwR7FiEFOILOWINGREASON(SEC.7031.SBUSINESSANDPROFESSIONSCODE:PNYGTYOA �� COUHTYWHICHREIXIIHESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOlISH,ORREPAINANVSTRUC � � NRE.iRIOR TO ITS ISSl1ANCE,ALSO REW IRES TME APPLICIWT FOR SUCX PERMIT TO FILE A SIGNED W Patio/Deck �W S7ATEMENT THAT HE OR SME IS IICENSEO PURSUANT TO 7HE PROVISIONS OF THE CON7MCTORS LI� W x CENSELAW(CHAPTERB(COMMENCINGWITHSECTION7000)OFOIVISION30FTHEBUSINESSANUPRO- V' POOUSPB ," FESSqNS CODE)Ofl TNAT HE ON SHE IS EXEMPTTHEREFROMAND THE BASIS FOR THE ALLEGED EXEMP• TION.ANVVKKATIONOFSECTION7o31.58Y4NVAPPLICANTFOflAPEflMITSU&lECT51HEAPPLICANTTO z Re-Roof k � ACMLPENALIYOFNOTMORElHANFNEMUNDflEDDOLUR5�5500�.): 3 � ❑I,ASOWNEROFTH[PROPERtt,ORMYEMPLOYEESWITHWAG[SA57HEIRSOLECOMPENSATION, CORImefCial 6 WILL DO THE WOp1(M1D THE STRUCTURE IS NOT INTENOED OR OFFERED FOR 5ALE(SEC 7066,BU51- � �; �. NESS AN�PROFFSS!ONS CODE:THE CONTMCTORS LICENsf t AW�oF.s NOT APPLY TO AN OWNER OF � PipPERTYW}IDBUIL�SORIMPROVESTHEREON,ANOWHODOESSl1CHWORKHIMSELFORHEASELFOR m � �� THROUCiHHISORHEAOWNEMPLOYEES,PflOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOEDOR � OFFEREOFORSALE.IF,HOWEVERTMEBIJILDIN�ORIMPROVEMENTISSOIDWRHINONEVEAROFCOMPLE- 6 Z TION,THE OWNER-9UILDER WILL HAVE TtiE BUROEN OF PROVING 7MAT HE OR SME DID hOT BUII.D OR IAIPROVE fOP iHE PURPOSE OF SqLE). � _ ❑I,ASOWNEROF7HEPROP�qil;M1EXCLUSNELYCOMRACIINCWITHLICENSEDCONTRRCTORS y 1� W TO CANSTRUCT THE PFOJECT(SEC.70�6,9USINESS AND PROFESSION6 COOE:THE CONTMCTOHS LI- _�.� �(,�,A1DJ.AREA p � Valualion � CENSEUWDOE3NOTAPPLYTOPNOY/NEFOFAPROPEFlTYWHOBUILDSORIMPROVESTNEREON.AND p WFiOCONTMCTSPoRSUCHPRQIECTEWITHACONTqq�TOR(S)LICF.NSEDPURSUANiTOTHECONTRAG QUANTITY DES RIPTION FEE p � TOIISLICENSEUW). / }. /�''� �. �i AM EXEMPT UNDEFl SEQ_ �� B.&PC.FOR THIS REASON Q �� ��` '�"� t R o —��. -- I U �r�'�' s u—' oaTe �'1 `�—��—'r�maex •`� � �"�-��_ U C�..l F� ' +. �. � LICENSED CONTRACTORS DECIARATION W ,t t�f�_ ` ��� � ��1 T�-'�!� a i, IHEPEBYNFFIPMUNDERPENALTYOfPERIURYTHATIAMLIGENSF,DUN�ERPROVI510N50FGM�PTEq � � t' � 9(C061MENCINO WITH SECTION 7000)OFONfS10N 30FTHE BU51NE55 AND P77qFESSION9 CODE,AND Z �p� Y��-I n L ' ��� MY LICENSE IS IN FUII FOFiCE ANO EFFECT. m �� ��!✓� � ; � UCENSE CLASS LIC.NO,_ __ � p J V UATE CONTftACTOR ,__.______,_ a F� � WORKERS'COMPENSATIUN DECLARATION � � � � EP�k�-C" iJ�,'i� ` � I HEREBY qFFIflM UNDER PENALN OF PEf7.1l1RV ONE OFTHE FOLIOWING OC:CIARAT10N5: Z . �: [ O �IHAVEANDWILLMAINTAINACEfiT�FICATEOFCONSENTTOSELF-INSUflEFORWORKERS' _ �q/ ',• S COMPENSATION,AS PHOVIOED BYSECTION 3)ooOFTHE LABOR CODE,FOH THE PEAFORMANCE U �� ^� �rpµ• L F QOFfHEWORKFORWHfCHTH15GFRAAITISIS3UED. � ? W _IHAVEANDWILLMAINTAINWORKERS'CAMPENSATIONINSUR�NCE,ASHEQl11REDBYSECTION 7 G 87000FTHELA90RCOOE,FORiHEPERFORMANCEOFYHEWORKfbHWHICHTHISPEPMITIS j� � ISSUEO.MYWORKERS'COMPENSRTIDNINSURANCECARRIERANDPOI.IGYNUMBERARE: CONSTRUCTION __���{d j — � � r e� —.__..._....— � j caawien_,._ PLAN RFVIEW �^`� -'7'�Y� _...--------...----- — � — -------"-- ) � POLICY NUMBEfl _- -._. ELECTRIC gy �A�A '� ___ _ f � (fi-1156ECIICNNFIDNO7BEOJA�LETeDOF71iEPEPo�fli5FY7RIXJEHUNURED�OLLMS(Stao�IX7lESS} PLUMBING � \,f ____,_ _ _ Z ICER7IFYTHATINTHEPERFORM0.NCEOFTHEWORKFORWHICHTHISPERMITISISSUF.U,1 MECHANICAL __.__,___..._ ___ _. � C> SHALLNOT EMPLOY ANV PERSON IN ANV MANNER SOAS TO BECOME SUBJECTTO THF, �Jj WORKEHS'COMPENSAiKMLAWSOFCRLIFOqN1A.ANDAGAEETHATIFISHDULDBECOME INSPECTIONFEE _____.___. ,__.__._ SU&IECT TO THE K'ORKEflS'COMPENSATION PFlOVISIONS OF SECTION 37000F THE LAdOR fJ /) �j CADE,ISHALIFOHTHWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCE ______ __. IV�(/ � p DATE: '__ APPLICANT: _'_'_ ____ SMIP __ _._....__...�.�_ I J WARNING FAILURE TO SECUFlE WORKERS'COMPF.NSpTION COVF.RAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C ___., . .__.__ ....___ ._____.__ _— � � SUBJECTANEMPLOYERTOCfiIMINALPENAlTIESAN�CIVIIFMF.SUPTOONEHUNDREDTHOUSANO ENERGYPERAAIT __... _._._______.. ,____. __..__, ; DOLLARS(f 1dl.000),IN PDDITION TO TNE COST OF COMPENSATION,DAMAGES AS PROVI�CU FOR IN � SECTION37080FTMELABORCO�E,INTEREST,ANDATTORNEY'SFEES. _ _ _ a� j RETENTION FEE: i____ OCUNSTRUCTION LENDING AGENCV PHE-ALT FEE: __..____,_.,__ .__.__, i � IHEREBYAFFIRMUNDEflPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY ____ ___ ___ _ ' FOR TNE PERf-0FMANCE OF iHE WORK FOR WHICH THIS DERIAI715155UED f�C.3097,CIV.C)- i Z "— "__. ..___ '_'_ W � LENDEWSNAME�"__'— _�... -- _.._..__ I h=' LENDEfl'SAO�HFSS .._ ..._.__ _._--. � W ICF.RTIFYTHATIHAVEREADTNISAPPLICATIONANDSTATETHATTHEABOVEINFOFMATIONISCORRECT. TUTAL FEES „� ��� � d IAGREEiOCAMGI.YWITHAILCITYAN�CAUNTVOR0INANCE5ANO5TATELAWSFELATINGTO�UILDING � CONSTRUCTION.AND MEflEBY AUTHOFlIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE ZABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSFS. COMMENTS p ' J __ � J ..t,ti�2 L A,t�(1 c�v - m --- -- Q EflMI1TEE AME(R�Nf) � _, .._ �� �1 -���"S`(_�_ }i ' � S RE OF PE TEE DATE ` " = RECPT.NO._ PAID BY VALIDATION__ 1 � ~ W HITE--0epaRment Capy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanYs Copy � z �. ..� _.,__ _._ .. __ .,,- _ ._ _ ._. _ . .. __.. . .._ ._. _ ,._' "' . "_ . � - . . � .. ,'..... _ \ . .x ! � � � I � - � . ' - � ' i ' � ; . I - i - ' . . � I � ' ' ' -� j I I � � 1 .. ���� ( I i r I i ' I , ' - ' � � . ' I �' ; �,�,� � ��Y � ' � I I i i � � ' i ' i I i , I i I � � � � � , � �t ! j, i F ..-I"_ ' ' �i— i I - � j � ' i ! i � ' ` i � � � . " . ' . � ( . � . q'� : - � i . . 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