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HomeMy WebLinkAbout17597 (25) CITY OF DIAMOND BAR COMMUNTTY DEVELOPMENT DEPARTMENT .„.,,� 21660 E.Coplcy Drive Suite t90 PRESS (909)860-3195 Fax(909)861-3117 � `""" BUILDINGPERMITAPPLICATION � FIRMLY a A DRIESS 2 � �' � V� 1 GI'��ia.�+. APPLICATION PERMIT P/C DATE NUMBER # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER _I'ti�F � ('�-I�S �i L .I e w.ti�J' ADDRESS �L 3 Y.. �C G��� ZONWG SET CKS Z CITY � rw 9� ZIP !�`JGJ"TEL.��D ' d�9G FRO RW ❑ p APPLICAN�f"G7/.��.r�" TEL s��'i,{= (o3S SIDE/SIDE STREET RW O Z Q CONTRACTOR SI�E ❑ � ADDRESS p CITY ZIP TEL. PROPOSED USE w ARCWEN ` /� � wDESIGNER � �.[Jxt�tti �I�ct�l L NO.DWEL. NO. NO. a ADDRESS l2ri 5 . �/�2Lf��sC � CITY��jr�r�t�L_.y3_� ZIP /76T TEI.S�IJ=e6.3S�1� UNITS STORIES BEDROOMS � - ui DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION , p� OWNER-BCILDER DECIARATION SFR/ADD/REM O �- � 1 HEREBY AFFIFM UNDER PENALTV OF PEFJURV THAT I AM EXEMPT FROM THE CONTRACTOR6 L6 G8f8J0/CBfpOfl W CENSELAWFOHTHEFOLLOWWGREASON(SEC.7031.58USINESSANOPflOFESSIONSCODE:ANYCITYOR (f� U CAUNTYWHICHREQUIRESAPERMITTOCONSTRUCLALTER.IMPFlOVE.�EMOLISH.ORREPAIRANYSTHUP W Pdtio/DBCk - W TUqE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W . � STATEMENT TNAY HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� . CENSE LAW(CHAPTEFi 9(CAMMENCING WITH SECTION 7000)OP DIVISION 9 OF THE BUSWESS AND PRP � � PooVSpa - FESSIONSCAD�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEOEXEMP- � � TION.ANYVIOLATIONOFSECTION7037.5BYANYAPPLICANTFORAPEflMITSUBJECTSTHEAPPUCANTTO Z Re-Roof . F ACIVIIPENALNOFNOTMORETHANFWEHIJNORE�OOLLARS(5500).): Q � OI,ASONRJEAOFTHEPROPERN,ORMYEMPLOVEESWITHWAGESASTHEIFiSOLECAMPENSATION, o mBCial Z WILL�O THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOfl SAIE(SEC.7044,8US6 J - � NESS AND PROFESSIONS CA�E:THE CANTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNEfl OF ♦p� PROPER�VWHOBUILDSOPIMPROVESiHEFEON,ANDWHO�0E5511CHWORKHIMSELFORHERSELFOR � �/awv (r TH4�OUGHHISOflHEllOWNEMPLOYE[S,PROVIO[DTHATSUCHIMPROVGMENTSAR[NOTINTENDEDOR m 1 : QOFFEREDWRSALEIF,HOWEVER,THEBUILDINGORIMPftOVEMENTISSOtDWITMINONEYEAflOFCOMPIE //V�D z. TION,THE OWNER-9UILDER WILL HAVE THE BUFDEN OF PROVING THAT HE OR SHE DI�NOT BUIL�OR = IMPROVE foRTHE PURPOSE OF 6ALE). - W OI,ASOWNEROFTHEPROPERTY,AMEXCLUSIVEIYCANTRACTINGWITML�CENSEOGONTRqCTOflS - � TO CONSTfiUCTTHE PROJECT(SEC.7a44,BUSINESS AND PROFESSIONS CODE:THE COMRACTOFS L4 V31Uefi0n ADJ.AAEA W CENSELAWOOESNOTAPPLVTOANOKTJEROFAPROPERTYWHDBl11LDSORIMPROVESTHEPEON,AND � F WHOCANTRACTSFORSUCHPRDJECTSWITHACONTFACTOP(S)UCENSEDPURSUANTTOTHECONTfiAG QUANTITY D CRIPTION FEE � TORSLICENSELAWJ. , . �� ❑1 AM EXEMPT UNDEfl SEC. B.6 P.C.FOR THI5 REASON Q � U - V"' �ATE � 'i OWNER^,(, � � � LICENSED CONTRACTORS DECLARATION W � i HEREBV AFFIRM UNDEF PENALTY OF PERJUHV THA7 I AM LICENSED UNDER PROVISIONS OG CHAPTER � - d. e(COMMENCINGWITHSECTION7a00)OFDIVISIONSOFTHEBUSMESSANDPPOFESSIONSCADE,AND Z �X MY LICENSE IS IN FULL FORCE AND EFFECT. m � LICENSE CLASS LIC.NO. j � J U �ATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARATIDN Q '' = U � I HEREBYAFFIRM UNDER PENFLTY OF PERJUFY ONE OF THE FOLLOWING DECLARATIONS: f (/� Z Q � _IHAVEANDWILLMAINTAINACERTIFICATEOFC�NSENTTOSE�F-INSUREFORWORKERS' $ Z CAMPENSATION,ASPROVI�EDBYSECTION37000FTHELABORC(�E,FORTHEPENFORMANCE U ¢ Of THE WOqK FOR WHICH THIS PERMIT IS ISSUED. � � w _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSEC710N n � O 37000FTHELABORCO�E,FORTHEPERFORMANCEOFTHEWOFKFORWHICHTHISPEFlMITIS ISSUED.MY WORNERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBEfi ARE: CONSTRUCTION � � Q �;i. � CARRIEF " ------,---.-------- PLAN REVIEW 3? Z POLICY NUMBER ELECTRIC �� Q � (f}IISSECTIONN�NOTBEOJMPLETEDOFTHEPEftMIiISFORONENUNDREODOtLAR5�5100)ORLESS} PLUMBING Z ICEHTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEFMITISISSUED,I MECHANICAL ____ kti (7 SHAILNOTEMPLOVANYP[(�SONINANYMANNERSOASTOBECOMESUBJECTTOTHE — (n WORKERS'COMPENSATIONLAWSOFCpLIFOFNIA,ANDAGHEETMATIF�SHOULDBECOME INSPECTIONFEE , �._ t SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR ci �'�: �� � O COOE,I SHAL(.FORTHWITH COMPLY WITH hIOSE PFOVISIONS. ISSUANCE 6.��3"t S I �- ��. p DATE: APPLICANT. SMIP � .-_ _�_________�_ ,._ S� � - ENERGY P!C �� E"@ 9- E`s3 f`'.I��i�:� �-'.�;'� J WARNING:FAILURE TO SECURE WORKERS'CAMPENSATION COVERAPE I5 UNLAWFUL,ANO SHALL BE �„,,.,,,,,,9•,� ;- LL SU&IECTANEMPLOYERTOCFIMINALPENALTIESANDCIVILFlNESUP700NEHUNDREDTHOUSAND ENERGYPERMIT ��p �q rYI� �AS°Fi':.� aJi'�C��d � DOUARS(5700.000j.IN ADDRION TO THE COS f OF GOMPENSRTION,DAMPGES AS PROVIDED FOR IN ��y{�k'� J SECTION37oeOFTHELA60RCODE,WTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: � — � � CONSTFUCTION LENDING AGENCY pRE-ALT FEE: ��-� � I HEREBV AFFIRM UNOEH PFNALTY OF PERJURY THAT THERE IS ACANSTRUCTION�ENDINO AOENCY FOR THE PER WRMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED(SEC.3097,CN.C.). Z W _._. ' � LENDER'S NAME 1— LENDEP'SRDORE5S � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEA80VEMFORMATIONISCORRECT. TOTAL FEES � w IAGREETOCOMPLYWITHALLCITYAN�COl1NTVORDINANCESANOSTATELAWSPEL4TINGTOBUILDING � � CONSTRUCTION,ANOHEREBYAUTHOflIZEFEPRESENTATIVESOFTNISCAUNTYTOENTERUPONTHE � Z ABOVE-MENTIONE�PROPERTY FOR INSPECTION VUHPOSES. COMMENTS � O 5 ly VJ i•�n( /' m ITTEENAME(PRINT) a �. � S g ,- � �, , • ,� ----- ___.._ N 0 AT E OF PERMI EE DATE A -� = RECPT.N . PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR06—File Copy,GREEN—AppllcanYs Copy i e � � ' ' ' I � I i F .. 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