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HomeMy WebLinkAbout17313 � CITY�F DIAMOND BAR --- "' --- L3EPARTMENT OF COMMUNI'TY&DE'VELOPMENT SERVICES � ft� MMU 21825 E.Copley Drive '' (909)�50-3195 Fax(409)861-3117 � PRESS BUILDIi�TGPERMITAPPLICATION �� FIRMLY JOBSITE APPLICATION PERMIT `�j P/C �} o ADDRESS������ �d���7y� DATE �� ' NUMBER �� � # a� � � a� ISSUE��' TYPE A�s OCC ,r� •- APN �� T TR.4CT DATE �' �I CONST. t� � P l."i�� � p OWNER �eyJ�� �'({,�s�j.f� GROU d ADDRESS �,r'�r'r� �1�''Z�� ZONING SETBACKS QCITY-�1}14sisLls : ZIP�`�.� TEL.��j�._'�,__� REART RW o p APPLICANT ,�'j,���° y�4�1,'� TEL. "�� SIDE/SIDE STREET RW ❑ z Q CONTRACTOR ^ SIpE O p� ADDRESS ��q, ' I�� ��. r � CITY ZIP TEL. � � PROPOSEDU3E FV/ip''CIC'JSS" �>sf�ttr�?�dsZ1�C�.��r�sL� ��,��f9iP✓l� L o ARCH/ NG/ �� �F�f.a� �''���'v"� ���+dd��`��- I Z DESIGNER r W NO.DWEL.�,/ NO. p NO. ��/ � ADDRESS UNITS �9 ' STORIES / BEDROOMSN` � � ' CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAI.UATION � OWNER-BUILDE,R CECLARATION SFR/ADD/REM � � � O � I HEREBY AFFIRM UNDER PENqLTY OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gfffd9E/C81POrt ' � W CENSEIAWFORTHEFOLLOWINGREASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCINOR (f� - ' Z. CIXINTYWHICNREIXIIRESAPERMIiT�CONSTHIICT,AITER,IMPROVE,�EMOLISH,ORREPAIRANY5TRUC- l,(J PatiolDeck � �, w TUFE,Pfl10R TO RS ISSIIANCE,AL50 REDUIftES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� W STATEMfiNT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � � CENSE LAW(CHAPTER 9(COMN�ENCING WITH 3ECTION 7000)Of DIVISION 30F THE BU5INESS AN�PR0- � POOVS(Je FESSIONS CODE)Oft THAT HE OR SHE IS E%EMPT i HEREFFIOM ANO THE BASIS FOR THEALLEGE�EXEMP- I U'��TION,ANYVIOL4TIONOFSECTION7031.59VANVAPPLICAN7FORM1PERMITSUBJECiSTHEAPPLICANTTO z Re-Roof I �A CIVII PENALTY OF NOT AAORE THAN FNE HUNDRED DOLLAPS�S50o7.): ❑I,ASOWNEHOFTHE PFOPERTV,OR MV EMPLOVEES WI7H3NAGE5 ASlHEIF50LE COMPENSATION, , Z�; � Commercia� - � WILL DO THE WOqK,ANO THE STRUCTURE IS NOT INTENOED GR OFFERE�FOq SALE(SeC,7046,8U51- _I . .�,'. NESS AND PPOFESSIONS CO�E:THE CONiRACTORS LICENSE�AW DOES NOT APPLY TO AN OVJNER OF � I ' . 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TOflS LICENSE LAW.�. �IAM EXEMPT UNDER SEC. 9.8 P.C.FORIHIS REASON �J° ,�I p . f U t d++. � f Q: � � �'l'� �ATE oWNER Us O �� a LICENSED CONTRACTOFS DECLAflATiON � S . ��'� IHEREBYAFFlRMUNDERPENALTYOFPERJURYTHATIAMLICENSE�UN�ERPHOVISIONSOFCHAPTER ""..,t� . . d' 9(COMMENCINC�WITN SECTION�000)OF�IVISIOtd 30F THE&1SINESS ANG PROFESSIONS CO�E,AN� Z X� MYLICENSEISINFULLFORCEANDEFFECT. m � LICENSE CLA55 '�' LIC.NO. ����P j � � �U� DATE � CONTRACTOR .��I'��Z.f����c�l.Y✓ a W � WORKERS'COMPENSATION DECLARATION a . � IHEREBYAFFIpMUNDERPENALTYOFPEflJ�RYONEOFTHEFOLLOWING�EC�ARATIOYS: z 'z� __IHAVEANDWILLMAMTAINACERTIFICATE�FC�NSENTTOSELF-INSLIftEGORWORKEqS' _ ¢. CAMPENSATION,ASPROVIDEDBYSECTION31000FTHELABORCO�EfORTHEPERFOflMANCE tU - �� OFTHE WORK FOR WHICF:THIS PEqM1T IS ISSUE�. � ¢Q, �I NAVE AND WILLMAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION ��� 370aOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFOflWHICHTHISPERUITIS ISSIIED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUMBFRARE: CONSTRUCTION � p � CARRIER �G.�f� �b°�- � PLANREVIEVJ .. Z PDLICY Nl1MBER 1���� � `�����' ELECTRlC e� . E ¢ p (11-0SSECl10NNEmNOTBECOMPLEfEDOF7HEPERMITISWRO�UEHUAYIRE�WLlARS(Stao)ORLESS�. PLUMBING w� ICERTIFYTHATINTHEPERFOpMANCEOFTHEWORKFOPWHICHTHISPEFlMffI5155UE�,l MECHANICAL Z' '(� SHALLNOTEMPLOYANYPERSONINANYMANNERSOAS'fOBECOMESl1BJEC'fTOTHE � � WORKERS COMPENSATION LAWS OF CALIFORNIA,ANO AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE . � SU6JECTTOTHEWaRNERS'COMPENSATIONPROVISIONSOFSECTION37000FTHElABOR � CO�E,ISHALLFORTHWITHCDMPLYWITH7H�ROVISIO� ISSUANCE � � SMIP �r ,� bATE: 9� � � APPLICANT: �. . ' J WPANING FAILURE TO SECURE WORHERS'COMPENSAT(ON COVERAGE IS UNL4WFUL,AND SHALL BE ENERGY P/C ^� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVIIFINESIIPTOONEHUNDREDTHOl15AN0 ENERGYPERMIT DOLLARS(51oo.aoo).IN ADDITION TOTHE CASTOF COMPENSATION.DAMAGES AS PROVIOED FOR IN � SEGTION 3108 oF THE LABOfl CODE,INTEREST,ANDAITORNEY'S FEES. RETENTION FEE: Z �o CONSTRUCTION LENDING AGENCY PREALT FEE: _ � IHEREBYAFFIRMUNDERPENPLTYDFPERIURYTHATTHEREISACONSTRl1CTIONLENDINGAGENCY FORTHE PER�OFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309].CIV.C.j. Z W � LENDER'S NAME — ' � !— LENDER'SAODRESS W� TOTAL FEES e�� � �� I CER7IFY THAT I HAVE HEAD THIS APPLICIITION AN�STATE THNTTF�EABOVE MFORMATION IS COFRECT. y p_ IAGREETOCOMPLYWITHALLCfiYAN�COUNTYOPDINANGE5AND5TATELAWSRELATINCaTOBUILDING � CONSTRUCTION,ANDHEREBYAUiHOFl2ERGPRESENTATNE50FTFI5COUNTYTOENTERUPONTFiE Z ABOVE-MEMIONED PROPERTY FOR INSPECTION PURPOSES. � �r �r, GOMMENTS � A �S P€ �"y�t°L� �'���iI�P C�3 q �°�'�',� e�`�c�.�.�. ��tv�t �► �,�, m PERMITT NAME(PRINT) R g � g /�O. 1 t�1� � SIGN FEOFPERMITTEE D TE —'--� � _ � RECPT.NO. PAID BY VALIDATION ~ WHITE—Depanment Copy,YELLOW—Finance Copy,PMK—Assessor Copy,GOLDENROD--File Copy,GREEN—qpplicanPs Copy - � � " . �+.��� , . :�#_�` , .�..� �� .... .. . � a s � Ra 4 . x . . 9F.�1' � . 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