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HomeMy WebLinkAbout17163 CITY OF DIAMOND BAR /`� �`` - DEPARTMENT OF COIvIl�1UNITY&DEVEL�PMENT SERVICES 21825 E.Copley Drive �r (909)$60-3195 Fax(909)861-3117 PR ESS BUILDING PERMIT APPLICATION FIRMLY } JOBSITE ' �(� APPLICATION �a,,,,�..� � NUMBER � t lf� PJC 0 ADDRESS_ � DATE � ISSUE TYPE OCC APN LOT ' TRACT• DATE CONST. GROUP p OWNER �I r�-i�.1 C S\ ,n._yT�� � p ADDRESS�� � _, ZONING SETBACKS z CITY ZIP TEL. FRONT RW ❑ p APPLICANT TEL. � S DE/SIDE STREET RW O � ¢ CONTRACTOR _ SIDE ❑ � ADDRESS � CITY ZIP TEL. PROPOSED USE QARCH/ENG/ w DESIGNER NO.DWEL. NO. NO. n_ ADDRESS UNITS STORIES _ BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNEq-BUILDER DECLARATION SFRlAD�/REM O � I HEPEBY AFFlRM UNDER PENALTV OF PERJURY THAT I AM E%EMPT FROM THE CONTPACTORS U- Gdfe9B/C8lPOf[ W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTVWHICHREOUIRESAPEFMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC� W PaS10/DBCk Z TURE,PRIOfl TO 175 ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll� W � CENSE LAW(CHAPTER 9(CDMMENCING WITM SECTION 7000j OF DIYISION 3 OF THE BUSINESS AND PRO- u' PooUSpa � FESSIONSCOOE)ORTHATHEORSHEISEXEMPTTHEREFROMAN�THEfiASISFORTHEALLEGE�EXEMV- (� � TION.ANYYIOLATIONOFSECTION7031.5BVANYAPPLICANTFOPAPEFMITSUBJECTSTHEAPPLICANTTO Z Re-Roof A CIVIL PENALTY OF NO'MORE THAN FNE HUNORED OOLLARS(S5W IJ: 0 ❑I,ASOWNEROFTHEPROPERTV,OPMVEMPLOVEESWIIHWAGESASTHEIRSOIECOMPENSATION. � Commercial Z WILL DO THE WORK,AND THE STRUCTUqE IS NOT INTENDED OR OFrEREO FOR SALE(SEC.7044,BU51- J � NESS AND PROFESSIONS CODE:THE CONTRAC7OR5 LICENSE LA'N OOES NOT A7PLV TO AN OWNER OF = PROPERTY WHO BUILDS OR IMPROVES THEREON,ANO WHO DOES SUCH WORK HIMSELF OA HEFSELFOp � THPAUGHHISORNEROWNEMPLO�EES,OPOVIDE�7HATSUCHIMVROVEAAENTSARENOTINTENDEDOR m . � OFFEREDFORSALE.IF,HOWEVER,THEBUILOINGORIMPROVEMEN715SOlDWITHINONEVEAROFCOMPLE � TION,THE OWNEF�BUILOER WILL HAVE THE OUR�EN OF PRDYING TI�IAT HE OR SHE DID NOT BUILO OR � IMPROVE FOR THE PURPOSE OF SAIE). w L'I,ASOWNEROFTHEPROPERN,AMEXCLl15WELVCONTRACTINGWITHLICENSE�GONTRACTORS [L TO CANSTRUCT TNE�ROJECT(SEC.7044,BUSINESSAND PROFESSIONS CODE:THE CONTRACTORS U- VOIUaI1011 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPER?YWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTRACi5FOR5l1CHPROJECTSWITHACONTRACTOR(S)LICENSF.DPLJRSl1ANTTOTHECONTRAG QUANTITY DESCRIPTION FEE x TORSLICENSELAW.). 0 ❑I AM EXEMPT UADER SEC. B.8 P.C.FOF THIS REASON Q � U LL � DATE OWNER U � LICENSED CONTflACTORS DECIARATIQN W 4 � IHEFEBYAFFIRMUNOERPENAITYOFPERJURYTHATIAMLICENSEDUNDERPROVI510N50FCHAPTER � Q 9�COMMENCING WITH SECTION 7000)OF DIVISION 30FT4E BUSINESSANO GROFESSIONS CO�E,AND z `X MY UCENSE IS IN FUL}�FO� EFFECT. m �� � LICENS� `� LIC.NO. � V DATE � GONTfiACTOP a W a� WORKERS'COMPENSATION DECLARATION � � a � I HEREBY AFFIRM UNDER PENALTY DF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: Z z _IHAVEANDWILLMAINTAINACERTIFICATcOFCONSENTTOSELF-INSUFEFORWOPKERS' _ CAMPENSA710N,ASPROVIDEOBYSECTION37aoOFTHELABOFCODE,FORTHEPERF09MANCE U 4 OF THE WOFK FOF WHICH THIS PERMIT IS ISSUED. � � W IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSt1RANCF.,ASREOt11REDBYSECTION ` �^ Q 3]00 OF TNE 4ABOR CODE,FOR 7HE PERFORMANCE OFTHE WORK FOR WHIGH THIS PERMii IS /�'�� � ISSUED.MV WO COM ENSATION URANCE RRIER AND POLICV NUMBER 0.RE: CONSTRUCTION �/t� Q > caqaiEq -����U PLAN REVIEW Z POLICY NUMBER ELECTRIC Q � (I}iI55ECTKKJNEmNOrBEGL7MPlEfFAOFTMEPEPMTISFORONEHUPDRED00LlAR5(5700)ORL65). PLUMBING � I CERTIFY THAT IN THE PERFOFMANCE OFTHc'WORK FOR'NHICHTHIS PERMIT IS ISSUE�,I MECHANICAL (;3 SHALLNOTeMPIOVANVPEASONINANVMANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOpGREETHA'IFISHOUIDBECOME INSPECTION FEE [' -�-����- - '^"'""' `-�"�:�� .���� SUBJECT?OTHEWORKERS'COMPENSA710VPROVISIONSOFSECTION37o00FTHELABOR 'j i .,�3 /ti f I � � GODE,I SHALL FOft HWITM GOMPLY WITpy THO�SE PROVISIONS. ISSUANCE F_.A�"rv /'f � J � ` ��� I..�F�'\ �, SMIP � �� p OATE:_�_ PPLICANT. � � ENEPGY P/C � WARNING FAILUFE TO SECUflE WORKERS'COMPENSATION COV GE IS U��LAWFUL,AND SHAIL BE LL SUBJEGTAN EMPLOVeRTO CRIMINAL PENALTIESAND CIVIL FIVES UG TOONE HUNDRED THOLISAND ENERGY PERMIT DOLURS(5�a0,000),14 ADDITION TO TNE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN �i � SECTION 3JOB OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: g���a�}_ � _�— 0. CONSTRUCTION LENDING AGENCY `'� �� - ' °`� � - PRE-ALT FEE: O � IHEREB�AFFlRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONI.EN�INGAGENCY d FORTHEPERFOflMANCEOF7HEWORKFOflWHICHTHISPERMITI5155UED(SEG.309],CIV.C.). — Z W S LENDER'S NAME �i' h— LENDEP'SADDRESS /`� � 1 CERTIFV THA`I HAVE FEAO THIS AP7LICATION AN�STATE THAT THE ABOVE INFORMATION IS CORRECT. TC�TAL FEES �l QL�� w I RGREE TO COMPLV W'�.TH ALL qTY AND COUNTV ORDINANCES 0.N�STATE LAWS RELATING TO BUILDING � � CONSTRUCTION.ANO MEREBV AUTHORIZE REPRESENTATIVES OF THIS CqUMY TO ENTER UPON THE z ABOVE-MENTIONED PROPEqTV FOR INSPECTION PURPOSES. COMMENTS p � _ ----__ m PER I E M RINT) " ��@,,�.-.. �j'-� 7 -�r � � SI AT E O�`PEFMITTEE DATE — � RECPt NO. 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