HomeMy WebLinkAbout14288 (17) � `rGd _1� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE5 _ W 21660 E.Copley Drive Suite 190 PRE$$ ,., ..�. (909)860-3195 Fax(909)861-3117 � �A�^ BUILDING PERMIT APPLICATION FIRMLY.� o�_ JOBSITE J��y/� ,,� APPLICATION ( �- �� ���NUMB R �"� #/C I . ADDRESS ���� !.to/� �/> DATE r� ISSUE TYPE OCC �: APN LOT T1�ACT DATE_ CONSt GROUP °C OWNER I✓f OO p ADDRESS C ZONING SETBACKS Z CIIY ZIP� TE . � REART RW �- g APPtICANT TEL. SIDE/SIDE STREET RW Cl �' CONTRACTO 4( j/ SI�E ❑ � ADDRE S �, CITY Z�p ` TE ' Jf' -- PROPOSED USE o.,; ARCHIENG! � DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES 9EDROOMS �- CITY ZIP TEL. y' DESGRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �" ��s OWNEFi-BUILDER DECLARATION SFR/ADD/HEM O; 1 HEflEBY AFFIRM UNDER PENALT/OF PERJUFY THAT 1 AM EXEMPT FftOM THE CONTRACTORS LI-- � (a`a�a98/C0lF10fI e.' CENSELAWFORTHEFOLLOWIN6REASON�SEC.7031.68USINESSANOPROFESSIONECODE:ANYCIlYOR (n � COUNTYYhflqiREGUIRESAPEflMiTTOCONSTHUCT,ALTER,IMPROVE,DEMOUSH,ORREPAIRANVSiRUG - W Patio/Dack � � � ? iURE,PRIOR TO ITS q9UANCE,ALSO REW IRES THE APPLICANT FOFl St1CH PERMIT TO FILE A SIQNED. -� W � STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO 7HE PROYISIONS OF THE CANTRAC70RS Lb - , CENSE LAW(CHADTER 9(COMMENC�N�WITH SECTION 7000�OF DIVISION 30F THE BUSMESS AN�PHO- � POOUSP2 �� fE3810N3CODE)ORTHA7HEORSNEISEXEMPT'l1�iEREfROMANOTHEBASISFORTHEALLEGEDEXEMP : TION.ANYVIOI,ATIDNOf8ECTIONT037SBYANYAPPLICANTFOflAPERMITSU&IECTSTHEAPPL�ANT70 - Z Re-Root �:: ACN{LPENALTYOFNOTMORETHANfIVEHUN�RE000LLARS(ESoaJJ: � OI,ASOWNEROFTHEPflOPERTY,ORMYEMPLOVEESWITHWAGESASTHEIASOLECOMPENSATION, � �mmercial �-, WAL 00 THE WOHK,ANU THE STRUCTURE IS NOT INTEN�ED Ofl OFFEflED FOfl SALE(SEC.706i,BU51- J - NE3S AND PROFESSIONS CDOE:THE CONTRACTORS uCENSE LAW DOES NOT APPLY 70 AN OWNER OF . �' PFiOPEHiYMJHOBUNASORIMPROVESTHEHEON,ANDWHODOE55UCHWORI(HIMSELFORHERSELFOp , m (L? TMROVUHHISORMEROYlNEMPIOYEES,PROVIDW7HAT5UCHIMPROVEMENTSRRENO7INTENDE�OR L�1� ,OFFERE�FONSAlE1F,FfOWEYERTMEOUIL�INGOR�MPROVEMENTISSDIDWITHINONEYEAflOFCORIPLE- - Z; 'TION,THE OWNER-BU�LDER WILL HAVE THE BURDEN OF PROVINa iHAT HE OR SHE DIU NOT BUILA OR ' _; IMPHOVEFOR7HEPURPOSEOFSM.E). ❑I,ASOVMEflOFTHEPROPEHfY.AMIXCLUSlVEIYCONTRIICTINGWRHLICENSEDCOPRflACTORS - ��.: TO CONS7RUCT lHE PRQIECT(SEC.7¢t4,BIISINESS PND PROFESSIONS�'AL`E:THE CONTHACTORS LI- ' VOItJe4iOf1 _ AOJ.AREA � W- CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILOSORIMPFiOVES1NEREON,AND _� WFIOCONTMCTSFOH8UCHPROJECTSWI7HACONT(il�GTOR(5)LICENSEDPURSUANTNTNECONTRAG QUANTIIY DESCRiPTION fEE ~"� TORS tJCENSE LAW.). �, —� /�� i H O. ❑I AM EXEMPT UNDEfl SEC. B.8 P.0.FOR THIS REASON ,c( I�A �'" � � 3 c� ---__--- cc , ' tL. DA7E OWNER �'" . W Q: L�CENSED CONTRACTORS DECLARATION W OC INEREBYAFFIHMUNOERPENALT(OFPERJURYIHATIpA1LICENSEDUNDERPFOVIS10N50PCHRPTEfl � ', � ;i(COMMENCIN(iWITHSECTION700o�OFDIV1310N30FTHEBU51NE5SANDPRO�ESSIONSCODE,AND z , X �MY LICENSE IS IN NLL FOFCEAN EFfECT. m - u� �e Q :LICENSECLAS LIG NO. � � 9 - � V DATE �� CONTRACTOR I-l��Z�u��. W , ��l � WORKERS'COMPENSATION DECLARATi6N -� U � IHEREBVAFFINMUNOERPENALTYOFPERJURVONEDFTHEFOLLQWINGOECtARATiONS: N � Q � �IHAVEAN6WILLMAI�TAINACEflTiRCATEOFCOfJSENTTOSELF-MSUPEFOPWOAKEHS' Z -- - � COMPfNSATIOk,ASP{tOVIDEOBYSECTION3]ooOFTHELABORCODE,FOFlINEPERFORRAANCE W OFTHE WORK FON WHICH TMIS PERMIT IS ISSLIEO. � � _I HAVE M!D WILLMAIKrNN W0(iKERS'COlAPENSRTION INSURANCE,AS REQUIRED BV SECTION Q 37000FTHELABORCODE,�ORTHEPERWRMANCEOfTHEWORKFQFWMICMTHISPERMITIS — _ ISSUED.MY WORKERS'COMPENSATION INSl1MNCE CARRIER AND POLICY NUMBER ARE - CONSTflUCTION Q _ > c�qiER E �' __ PLAN REVIEW Z PIX.ICY NUMBER — --��-� ELECTS�IC _ C � (II-uSSEC1UNNE�NOTBE�LkIEDOFi}�PERtaTiSP�RIXVEFAA�DFiEDOq1ARS(StOD1C1HLFSS). PLlJM81� NG,_�� � , -_ W MECHANICAI ��� �� — Z I CEHTIFV THAT MI7HE OERFORMANCE OP 1HE WORK F�N WHICH THIS PERMI715 ISSUED,I -�`����5�` � SHRLLNOTEMPLOYANYPERSONINANYMANNERSOAST09ECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _ S SU&IECTTOTHEYJORKERS'CQMPENSATIONPROVISIONSOFSECTION3TOOOFTHELAeOH �SSUANCE CAbE,I SHALL FOft1HYlITN COMP!Y WIhiTHO&E PROYISICNS. g ( p� p DA7E: APPLICANT. SMIP Y�� ,�, f�d A�`£� . � ENERGY P/C �� J. WAFWING:FAILURE TO SECURE WORNERS'CAMPENSATION COVEflpGE IS UNLAWFUL.AND SHALL BE ' -"—� LL, SUBJECTANEMPIOYEflTOCRIMINALPENPLTIESANOCIYILFlNESUPTOONEHUNDREDT}iOUSAN� ENERGYPERf+��j � �"� ��-�'"E����`-''� �„ DOLLARS�St00.000),INA�DITIONTOTHEGOSTOFCOMPENSATION,DAMAGESASPROYIDEDFORIN �� `,�k y�a�yy�'_..-_ :;...;y A� _I SECTION 37080F THE LABOR CODE,INTEREST.ANO ATTORNEY'S fEES. RETENTION FEE: � - W CONSTRUCTION LENDING AGENCY pRE-ALT FEE� a �. i HEREBV AFGIRM UN�Eii PENALTY OF PERJUFY THAT THERE IS ACONSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OF THE WOflK FOR WHICH THIS PEflM1T IS ISSUED(SEC.3097.CIV.C.). W �Z LEN�ER'SNAME ___ � F- IENDER'SADORE55 ��l ` � ICEHTIFVTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEINFORMATtONISCORRECT. TOTAL FEES �� („�' J} � IAGREETOCAMPLVWITHALICITYANDCAUNNORDINANCES/WOSTATELAWSRELAiINOTOBUILDING ' � (�� � CONSTRUCTION.ANDHEHEBVAUTHORIZEFEPRESENTATNESOFTHISCOUNTVTOENTERUPONTHE - Z q80VE-MENTIONEDPROPEH7YFORINSPECTIONPURPOSES. COMMENTS ---- � �. ��� OPd b' - . PERMITTEE NAM y / �ry ` .� � /������ `t "1 `��}�._.� � t � SIONAT�RFOFPEFMITfEE E �.,se � '�� VALIDATION � RECPT.NO. 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