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HomeMy WebLinkAbout11054 (5) -1�— CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT D�PARTMENT 21660 E.Copley Drive Suite 190 PRES•S• x (909)860-3195 Fax(909)561-3(1? ���'""", BUILDINGPERMITAPPLICATION FIRMLY o� JOBSITE � � APPLICATION ������� PERMIT P/C ADDRESS DATE NUMBER # � ISSUE TYPE OCC APN O �RACT i DATE CONST. GROUP p OWNER � u" ADDR � ZONING SETBACKS z CITY i f> ZIP TEL. FRONT _ RW fl p APPLICANT TEL. SID SIDE STREET RW ❑ z Q CONTRACT R � __ SIDE ❑ p� ADDRE S 'e� PROPOSED USE � � � CITY ZIP � TEL. � ARCH/ENG/ z DESIGNER , b W NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � �n �,_ DESCRIPTION SQ.FT. FACTOR PSF ADJ..AREANALUATION p� OWNER-BCILDER DECLARATION � SFR/AO�/REM O I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gef8J0/Cd�pOfl �W CENSELAWFOFTHEFOLLOWIN�FEASON(SEC.7o31.5BUSiNESSANDPROFESSION3CODE:ANYCITYOR (J� U COUNTYWHICHREQUIRESAVEHMITTOCONSTRUCT,AUER,IMPROVE,�EMOLISH,OflREPA1RANYSTRUG� W PatiolDeck z TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SH[IS LICENSED PUflSUANT TO TI IE Pf10VI510N5 OF iHE CONTflACTORS ll- W � CENSELAW(CHAPTER9(CAMMENGINGWITHSECTION70W)OF�NISION30FTHe0USINE55ANDPRO � PooVSpa O FESSIONSCOOE)ORTHATHEORSHEISEXEMPTTHEFEFROMANDTHE6ASISFORTHEALLEGEOEXEMP- (� � V TION.ANYVIOLATIONOFSECTION7a31.5BYANYAPPUCANTI"OfiAPLRM1TSl/8J[CTS'H[APPLICANTTO Z Re-Roof A CIVIL PENALN OF NOT MORE THAN FIYE HUNDRED DOLLARS(S5o0�J: zOI,ASOWNEROFTHEPflOPER7V,OflMYEMPLOVEESWITHWAGESASTHEIR50LECOM7EN5ATiON, O COrtlrtlefCiiil WILL�O TNE IVORK,AN�THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BU51� J � NE55 AND PftOFES510N5 CODE:THE CONTRACTOflS LICENSE LAW�OES NOT APPLY TO AN OWNER OF � � PROPEPTY WHO BUILOS OR IMPROVES THEREON,AND WHO DOES SUCH WOflK HIMSELF OR HfRSFt.F OR � THROUGHHISORHEflOWNEMPIOYEES,PROVIDEDTHATSUCHIMPROVEMENTS�RENOTINTENDEDOR m 0 OFFEREDFOFiSALE.IF,HOWEVER,THEBUILDINGOftIMPflOVEMEMISSOLDWITHiNONEYEAflOFCAMPIE � TION,THE OWNEF-BUILOER WILL HAVE THE BUROEN Of PROVING THAT HE.OP SHE DID NOT 6UIlD OR � IMPflOVEFORTHEPURPOSEOFSALE). - W ❑I,ASOWNEROFTHEPROPERTY,AMEXCI.USIYELVCONTRAGTWGWITMLICENSE�CONTRACTORS � TO CONSTRUCT THE PflOJECi(SEC.7044,9USINE55 AND PFOFESSIONS COOE:THE CONTRACTORS U- VdlUetlOfl � ADJ.AREA W CENSEL4WDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND ' = WHOCONTRACTSFORSUCHPR0.IECTSWI7HACONTFACTOP(5)LICENSEDPURSUANTTOTHECONTRAC- �UAN7ITY DESCRIPTION FEE ~ TORSUCENSEIAWJ. Y - � ❑I RM E%EMPT UNDEfl SEC. 8.&P.C.FOR THIS REASON Q � U � � DATE_ OWNER __. U . .. � , _ . Z W � LICENSED CONTRACTORS DECLARATION W � I HEREBY AFF�RM UNDER PENALTY OF PERJURY THAT I AM LICENSE�UNDER PROVISIONS OF CHAPTER �, . p„ 9�COMMENCINGWITHSECTION7000)OFDIVISION30FTHE6USWESSANDPPOfESSIONSCODE,AND Z X MY UGENSE IS W FULL FORCE AND EFFECT. � LICENSE CLASS '� LIC.NO. � � � F- o J U DATE� CONTRACTOR d � �'""7�OfiKEftS'COMPENSATION DECLARATIO Q � IHEREBYAFFIflMUNDEHPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLAHAfIONS: � � � -Z _IHAVEANDWILLMAINTAINACERTiFICATEOFCONSENTTOSELFINSUqEFORWOqKERS' _ - � COMPENSATION,ASPFOVIDEDBYSECTION3700OFTHELABOFCOOE,FORTHEPERFORMANCE U ¢ �OFTHE WORK FOR WHICH 7HIS PEFMIT IS ISSUED. � � W I NAVEAN�WILL MAINTAIN WORKEFS'COMPENSATION INSURANCE,AS flE�UIRED BY SECTION ' O 37000FTHELABORCO�E,FORTHEPERFOFMANCEOFTHEWOF7KWRWHICMTHISPERMITIS - • %�J� ISSUED.MYWORNE 'CO P SATI IN9U CARR� ANDPOLICYNUMBERAFE: CONSTRUCTION O" J j CARRIER PLAN REVIEW Z POLICV NUMBEfl �`� ELECTRIC Q � (IHISSECf10NNEmNOiBEO7MPLETE�OFTHEPERMfI'ISFORONEHUROREDOOLLARS�E100) ). PLU�� W �,�* . Z I CER7IFV THAi 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,l MEGH CS SHAILNOT EMPLOYANY PGF7SON IN ANY MANNEfl SO AS TO BECAME SUBJECT TO THE - ' (/) WORKERS'COMPENSATIONLAWSOFCALIFOFINIA,ANOAGREETMATIFISHOULDBEGOME NSPECTIONFE ` � SUBJECT TO THE WORKFRS'COMPENSATION PPOVISIONS OF SECT 3700 0F THE LABOfl � CO�E,1 SHALI FDRyTH�WITH COMPLY WITH jbl� �PROVISIONS7 ��C . � �!'C���',/ 6' ./ � SMIP � �� p DATE� fi_ APP�ICAN7:� / J WARNING:FAILURE TO SECURE WOPKERS'COMP NSATION COVERAGE IS UNL4WFUL,ANO SHALL BE ENERGY P/C � SU&IECTANEMPIOYERTOCflIMINAIPENALTIESANDCIVILFWESUPTDONEHUNDHEDTHOUSAND ENERGYPERMIT OOLLARS(St00,dW),IN ADDIiION TO THE CO5T OF COMPENSATION,DAMAGES AS PH�VI�ED FOR IN � SECTION 3�ae OF THE LABOR CO�E,INTEREST,AND ATTORNEV'S FEES. - RETENTION FEE: d CONSTRUCTION LENDWG AGENCY PRE-ALT FEE: - O � 1 HERE9YAFFIRM UNDER PENAITY OF PERJURV THAT THERE IS A CONSTPUCTION LENDING AGENCY � FOFI THE PERFORMANCE OF THE WORK WR WHICH THIS PERMIT IS ISSUED(SEC.3oH],CN.C.J. Z r^. W � LENDER'SNAME... .__ . . H LEN�ER'SAODRE55 � � TOTAL FEES � I CER7IFY THAT I HAVE REA�THIS APPUCATION AN�STATE THAT THEABOVE WFORMATION IS CORRECT. - W I AGREE TO COMPLY WITN ALICITY AND COUNTY ORDINANCESAND STATE LAWS RELATING TO BUILDING � � CONSTRUCTION,AND HEPEBV AUTHORIZE REPRESENTATlVES OF THIS COUNTY T TE PO�I THE - - � ABOVE�MEN D PfiOPERTY FOR INSPEC710N PUFPOSES. z- COMMENTS � � "� J � � PEHMI E IPRINi) .. f��� ..� . . ¢ " / _ — .__ � �..__ . � S A7UR O PEHMITTEE - �� � DATE ' ' - , RECP7 NO. 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