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HomeMy WebLinkAbout17112 J� CITY OF DIAMOND BAR � l DEPARTMENT OF COMMLMITY&DEVELOPMENT SERVICES ^� 21825 E.Copley Drive . (909)860-3195 Fax(909)861-3117 PRESS '-.� BUILDING PERMIT APPLICATION FIRMLY o DDRESS d�� � �` 6 DATECATION � 1 �J1 NUMBEFl ��I� MIC c� _ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �n• N� ADDRESS : C-C' P/� . ZONING SEfBACKS OCITY D��f�%�� Pr_ ZIp I � TEL. ^ i_^C1-S I FRONT RW ❑ o APPLICANT �ptt�� f�l.lZc . TEL.s?c'+�i(,3-Nod'� REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR � S r N SIDE ❑ � ADDRESS � C• • VF . � � CIN � .�• � � ZIP .� TEL.?�+�-��Rr-AC PROPOSEDUSE �w ARCH1ENG/ � DESIGNER � ADDRESS NO.DWEL. NO. NO. UNITS STORI ES BED ROOMS � CITY ZIP TEL. � � DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDEA OECLARATION SFR/ADDlREM O p I HEREBY AFFIRM UNDER PfNALTY OF VERAIRY i}IAT 1 AM E%EMPT FROIA iM'e CONTMCTORS L4 GaragelCarport W LENSELAWFORTHEFOILOWIN(iREA50N(SEC.70]1.68USINESSMD7RCFESSIONSCOOE.MlYCITYOR (n U COUNTVNMICHREOUINESA7ER4RTOfANSTRUCT,A:TER,IMPROVE.DEMOLISH.OAREPAIRANYSTRUG W Patio/peck WTURE,PH10F TO ITS�SSUANCE,AL50 REOUIRES THE�7DUCANT FOR SUCH 7ER1AR TO FILE A SIGNEO w � STATEMENT iHAT H[OR SHE IS UCENSED NRSUM7T TO TME PROV�SIONS O�iH5 CONTRACTORS LI• � GENSE UW(CMAPTER Y(COMMENCIHO WITH SECTION 7000)OF�IVISION�OF THE BVSINf55 AND PPO� � POOVSP3 iE55qN5 COOE)OR 7HAT ME OR SME IS EXEIAPT TNENEfflOM AND THE BA515 FOR THE ALLEGED E%EAIP� V TION.ANYVKKAiqNOFSECTION70�1.6BYANYAPPLIGANTFORAGERMIT5U8JECT3THEAPPLICANTTO Z Re-Root � ACMLpENQ7YOFNOTMORETWINFNEHUNOREDDOLURS(fSOD)): � � ❑IASOYINEROFTHEPROPERTY.ORAIVE�PLOYEESWITHWAGE5A5THEIRSOIELOMPENSA710N, O (;pmmBrCid� z 1NLLDOTNE WORK,M1D TF1E STRl1CTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC.70N,BUSb J � NESS AND OROFESSIONS CODE:THE CONTMCTORS UCENSE UW�OES NOT APVIY TO AN OWNEH OF [f n VROPERTVVRIOBUILOSORIMPROVESTHEREON.ANDWNODOESSU[HN'ORKNIMSELFORHERSELFOq � �^L� ^ 1 � '� / (L 7Hii0UGMHISORHEROWNE�PIOYEES,PROVIDEOTHATSUCH4APROVEI.�ENTSARENOTINifNOEDOR m /��,,� � OFFEREDFORSKEIF,HOWEVERIHEBUIlDIN60RiMPROVEMENi1S50LDWITIINON[VEAROFCOMPIE �/,I1/l.C?� �1 JlIG1 /.+(,fJ/J Z TION,TME OWNER-BUILDER WiLL NAYE TNE BUROEN OF PHOVINO TMAT HE OR SH:�i0 NOi BUIID OR = pAPROVEFORTHEPURPOSEOFSAIE�. w OlA50WNEROFTHEPROPEflTY,M1E%CLUSNELYCONiMCTINOWRHUCENSEDCONTRACTORS � TO CONSTRUCT THE iROJECT(SEC.70u.BUSINESS ANO PROFESSIONS CODE:TNE CONTMCTOFS L4 Vd1032i0l1 � � AD.I.AREA W CENSEUWDOESNOTAPPLYTOANOwNEROFAPROPEHTYKT108URD50RIMPROVESTHEREON.AND � W11000MMCTSFORSUCHPA0.IECTSVATHACONTMCiOR(5)LICENSEDPURSUANTTOTMECONTRAC• QUNITITY DESCi71PT10N FEE Y TORS UCENSE UW). , � O�AI.�E%EMP7 UNDER SEC. B a P.C.FOR iHiS REASON U r-L• �F`1� •� � � u" OATE �WNER V � LICENSED CONTRACTOF7S DECLARATION -r ¢ , w [t IMEAEBYAFFIRMUN�ERPENALTYOFVERJURVTHATIAMLICENSEDUNC[RPf10VISiONSOFCHAPTER U. p., Y�COMMENCWGWRIISECTION7000JOFDIVISION]CFTMEBUSINESSMI'JVROFESSIONSCODE.MlO Z X 4Y IICENSE IS IN FULL fOPCE AND EFFECT. � �� �� m LLl Q � LIGENSEC B NIG IIC.NO. / J V DATE����d[1f�I CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION a � U � I HEREBV�FFIRM UN�ER PENAITY OF PE0.AIRV OhE OFTHE FOLLOW�NG DEp.AM110N5. � 2 Q C _�W�yEµ�WiLI MAINTAIH A CERTIFICAIE OF CONSENT TO SEIF-INSURE FOR WORKERS' $ � CDAIPENSA7qN,AS PFOVIDED BY SECTION 770a OF 7ME LIt70R COOE.FOR 7HE VERFORMANCE W OF 7HE WORK FOR WHiCH 7H15 VERMIT IS ISSUED. � � �IHAVEANDWILLMAMTAINWORKERS'COMPENSATIONINSURANCE.ASREC4JI0.EDBVSECTION Q �700 OFTME UBOR CODE,FOR THE PERiORAUNCE OF THE wORK fOR YhIICH THIS PERMIT IS ISSUED.IAYNURKERS'COA�PENSATIONINSURANCECARRIERAN�POLICYNUMBERME. CONSTRUCTION ��u � GRRIER J�TA�Y" (�_15M P /NS. FtJ N� PLAN REVIEW � POLICVNUMBER�18��.�� ' ELECTRIC b�� ���I� � (MSSEG7qNNEmhATBECCMPLETEDOFTIEPEPMT6F�i0NEV�.f1NL"�OC11.�SKtro)IXiLE55} PLUMBING w MECHANICAL Z I CERTIiV THAT IN THE PERFORMANCE OF THE NbRK FOR Y1FiICH 7H15 VfPAIIT IS ISSUE0.1 _ _ _ Q} SHALLNOTENPLOYANV7ERSONINANVMANNERSOASTOBECOE!ES JECT THE ,�`�� �;;\ � I � i �`�, � KORI(ERS'COMPENSATIONUWSOFCALIFO�NI�A. �GREETHATIf ,H OELOAIE INSPECTIONFEE �•0 S SU0.IECTTOTHEWORKERS'COAIPEN PROV -0NSOFSECT 37 ;EUBOR �SSUANCE CO ISM LLFORTFIWi7HCOMVLYWI 1 SE ONSiONS. O n . SMIP � p OATE: ` 1 � APPLICANL ,� - - . � ENERGY P/C � WARNINO:FAILURETOSECUREWORKERS'COM NSA WC VERAGEISUN WFiL,ANDSHAILBE � SUBJECTANEMPLOVERTOCRIMINALiENATIE MD LF ESUPi00NE REDTHWSAND ENEFGYPERMIT � . � ' DOIURS�S100,0oo).N/�DOITIONTOTMECOST COM Y ipN.DAMACES PROVIO[DFORIN �t �'�'- ¢ SECTION�70e OF T17E IABOR CODE,NTEREST, 0� � eY5 FEES. RETENTION FEE: -"""� -- - -- - pW_, CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � IHEREBYAFFlRMUNDERPENALT/OFGERIUFVTHATTMEREISACONSTRVClIONLENDINOAGENCY n- FOR TME PERFORMANCE OF TME WORK FOR WHICH THIS GERMIT IS ISSVED�SEC.io97,dV.C.). Z w � LENDER'S NIu�E � LENOERSADDRESS ^ ,{, w ILERTIFYTHATINAVERE/�DTHISAFPLICATIONIWDSTATETMATiHEABOYLY:FORMATqNISCORRECL TOTAL FEES •a U d 1/1GFEE TO COMPLY WITH ALL CITY/J10 COUNTY OR�INANCE511ND STATE UWS REU71rvG 708URDING fANSTRUCTION.AND HEREBV AUT110RIZE REPRESENTA7IVES OF TNIS COUNTY TO ENTER UVON THE ZABOVE�MENTIONE�DROPERTYiORINSDECTIONPURVOSES. y COMMENTS � .-�o "P �' �No pL� ¢ ccwairree E cP n C� � L� n� � SiGNATUREOFP E �p� ', RECPT.NO. 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