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HomeMy WebLinkAbout15487 (20) 1 __�.�_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ 21660 E.Copley Drive Suite 190 PRESS ��)s6o-3i9s����>sbi-sii� FIRMLY »����� BUILDIIVG 1'ERMIT APPLICATION JOBSITE - � �{ .�{ � APPUCRTION '' � PERMIT /JC P/C �°'• � ADDRESS ��� � """"'��""�" DATE �' ` � NUMBER i� # � ISSUE ^� � TYPE OCC APN LOT TRACT DA7E '� �°' GONST. GROUF p OWNER �� .k---�� LL ADDR S ?.S � � � �•�4 ZONING SETBACKS z CITY ZIP F� TEL. � �_ FRONT RW ❑ TEL. REAR � ; g APPUGANT SIDEISIDE STREET RW ❑ Q S1DE N ❑. � CONTRACTOR � ADDRESS PROPOSED USE � CITY ZIP TEL. w ARCHIENG/ Z 'DESIGNER NO.DWEL. NO. NO. a ADDEtESS UNITS STORIES BEpROOMS ' yGITY Z!P 7EL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION , :-,�: - OWNER-BUILDERDEGtARATION SFR/ADD/REM ' p � � I HEpEBY AFFIFUI UN�ER PENAL7Y OG PERIURV THAi i AM E%EM?T FFlOM THE CON7F11CTORS LI- G8f898(Cflf(JOfI �,W CEP35ELAWf-0HTHEFd.LOWMGREA50N(SEC.7N1.58USINESSANOPROFESSION5CADE:ANYCITYOfl (n . .� C,] COUNfI'WHICNREWIRESAPERMIT7000NSiRUCT,ALTER,�MPfiOVE,DEMOLISH,ORREPAIFANYSTRUG ;� patl0/D6Ck �� ,�Z TJflE;PRIOR TO ITS ISSUANCE,ALSO REt]UIRES'fHE APPLICANT FOF SUCH PERMIT TO FILE A SIGNED 2 SiATEMENT THAT HE Ofl SFIE IS LICENSED PURSUANT TO TFiE PflOVISIONS�F THE CDNTRACTORS U- .�C ��CENSE LAW(CNMTER 9(COP�MENqNG WRN SEC710N 7a0D)OF DIVISION 30F THE BUSINESS PNO PRO� � POOI/Spd V FESSIDNSWDE)DRTHATHEORSHEISEXEMPTTHEREFROMAN�THEBASISFORTHEALLEGEDfXEMP- �„Ly '�TKKJ.ANYVIOI.ATIdNOFSECT10N�031.5BYANYAPPLICANTFOAAPERMITSUBJECTSTHEAPPLICANTTO Z R8-ROOf ,�,� ,A CML P:NALTY OF tJOT IAOFE THAN FIV'c HUNDRED DOIURS�E500).): , . � .^ ' ❑I,AS�WNEROFTHSPROi�ERTV,ORAIYEMPLOYEESWITHWAGESASTHEIR50LECOMPENSATiON, � COf11R18fC18I L �WILL 00 THE WORK,AND T'��E STRUCTURE IS NOT INTEN�EO OR OPFESED FOF SALE(SEG 7oa4,B1J54 J "� NESSAND PFiOFE99lONS WDE:T/1E CON7AACTORS LICENSE IAW DOES NOi APPLV TO AN OVINEF OF = � �:PROPEHTYNMO6UILDSORIMPfloVESTNEREON,ANDWHO�0E5511GNWOFiKHIMSELFORHERSELFQR ��(C �TNRIXIGH NIS OR HER OWN EMPLOYEES,PROVIDEO THATEUCH IMPROVEMENTS ARE NO7INTENOEO OR � m � � i '���,�i OFFEREDFORSALEIF,HOWEVEFLIHEBULDINGORIMPR�VEMENTIS501DWITHINONEYF.APOFCOMPLE ,i� .;710N,THE OWNER-BUILCER WILL HAVE THF BURDEN�F PROVING THAT HE OR SHE DID NOT BUILD OR ,= IA7PR6VEFORTHEPURP�SfiOPSALE). . �,�W "�❑I,ASOWNEROFTHEPROPERTY.AMEXCLUSIVEIYCANTRACTINOWITHLICEN°EDCONTPACTORS , TO CONSTRUCT THE PflOJECT(9EC.'7044,9U3WE33 AYD PRCFESSIONS CODE:?HE CANTRACiORS LI� I V8�I118}IOPI ADJ.AREA LLi .CENSELAWDOESNO'APPLYTOANOWNEROFAPROPEftNWH'JBUILDSORIAiPR6VE5THEHEON,AND � � � ��N7iDGoNTRAdTSFORSUCHPFOJECT9W11HACONTRACTOR(S)LICEPISEDPURSUANTTOTHECONTRAG j (}'tJA 7y DESCRPTkBN FEE � � Y '..TORS LICENSE U1W.). ,'.�I " , �o ❑I AM EXEIUPT UN ER SEC. P.C.FOR THI6 REASON .�U I :�z' .DRTE OWNER_ �; . . O W II � UCENSEp CONYRACTOR5 6tGLARATION � ��. 1 HEREBVAFFIMI t1N�ER PENALTY OF PER.JURV TNAT 1 dM UCENSED UNDER PROVISION6 OF CHAPTER ,� , ' p„'�' 9(COMlAENCINGWITHSECYION?00�)OFDIV�SION30FTHEBUSINESSAN�PROFESSIONSCODE,AND z X,; MYUCENSE�S N FUL�FORCEANp EFFECT. m .. � . ', Ll.l � 0.��..'�UCENSE CLASS LIC.NO. .J . . V...DATE CONTMCTOR � , . W �.� WOFKER9'COPAPENSATION DECL4RATIQN � � U ��, IHEAE6YAFPIRMUNDEFPENAC7YOFPERNRYON"eOFTHEFOLLOWINGDEQARATIONS: Z Q �. �IHAVEMAWILl1AAtNTAINACEATiFICRTEdFCANSENTTOSELF•INSUREFORWOflKER$' 2 -- � � CAMP£i15AT10N,A5 PR041�ED BY SECTION 3700 OF THE L4BOR COOE,FOH THE PEflFORlAANCE �W OF STtE WORK FOR WHICH TNIS PERMI7151SSUED. � �� �� _t HhVE MD WILL MAWTAIN WOP.NERS'CONPENSATION INSURANCE,AS REQUIRED 6Y SECTION ���' 37070F"ME LADdR CDDE,FORTHE PEHFORMANCE OFTHE WORK FOR WHICH THIS PcRMIT I5 ISSUED.NY WOR%ERS'COMPENSATION INSUflANCE CARflIERAND POLICY NUNBEfiARE: CONSTRUCTION �,i, � PLAN REVIEW _ J�T�"— ,. CARRIER_ Z.�, aOucvNunsBER ELECTRIC . ¢� (lFiIS5ECIIGNNE�NCTBEO�N�LEfEDOF7F�ePEfi�YTl WAONEFIlN'x7RE�00U.ARSIStCQ10flLE5S). PLUM8ING wi ��'�, ICERTIFYTHA7IN?HEPERFORMANCEOF?4EWOPKKORWWCNTHfSPERM1TI51SSUE0,1 MECHANICAL (�$��I SHALL NOT EMPLOV ANY PERSON IN PNtl MANNER SOAS TO B'cCAME SUBJECT TO THE � ��I WORKERS'COAIPENSAiIQNLAW50FCpUFORNIA,ANDAGREETHATIFISHOULDBECOME INSPEGTION FEE � �I�� SU0.1cCT TG TF1E NiORKERS'COM?EtdSATqN PROV15lCNS OF SECT{Otd 3'!0o OF'HE Lh90� . . �, j,: CQOE,1 SHALL FORTSiWITH GOMPLY WI1N THOSF PROYISIONS. ISSUANCE — _�„ �O�e� � SMIP � l p'.I DATE:� APPLICANF: }g9� � J� M1ARNiNO:FAiLUFtT05£CUREWORI:ERS'COMPENSATIONCOVERAGEISUNLAWfUL,ANOSHALL6E ENERGYP/C �����7,p— '�.�'�. SU&1ECTANEMPLOYEflTOCRIMINALPENALTIESANDqViLFINESUPTOONEHUNDRWTHOUSAN� �'"� WLlARS(f7C0,0a�)JNAODITIONTOTHECOSTOFCONPENSATION,DAMAGESASPROVI�EDFORIN ENERGYPERMIT y �y - . ��,�.I SECTION 3')DB OFTHE LABOF C06E.INTEREST,ANDATTORNEY'S FEES � fi✓$�$ ��' ' '� 1 Y ��� `�— '� , RETENTION FEE: ��, CONSTRUCTION LEfdDSNG AGENCY PFE-AL ��-������������ O ��I� I HEPEEYAFFIRM UN�ER PENALTY OF PERJl1RY THATTNERE IS A CONSTftl1CTION LEN�ING AGENCY _ �-��� FOF THE PERWRMANCE OF7HE WORK FOR WHICHTHIS PERMIT 7515511ED iSEC.3os�,CIV.C.). � � ' . � Z J� W,; _ �', LENDEFS NAME _—� !—����LENDEF'SADDAESS C . . � �.��' ICERTIFYtHATIHAVEREADT411SAPPLICATIONANDSTATETHATTHEABOVEINFORMAT10NI5CDRPECT. TO�AL �CES ' � � W ..IAGREETDCOMPl.VW{THAi1CITYAh6COl1NTVOR�INANCESANOSTATEUWSRELATINGTOBUILDING ����CANSTRIN:TION,ANDHEREBVAUTHOR2EfiEPRESENiATIVESOfTHISCAUNTYTOENTERUPONTHE � - , � Z �ABO�IONE�PROGERTVFORINSPE PURPOSES. 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