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HomeMy WebLinkAbout16320 (23) CITY OF DIAMOND BAR �j � ������ , -- DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � � 3� � /(/ V w 21660 E.Copley Drive Suite 190 t ��I (909)860-3195 Fu(909)$b1-311? PRESS �"�'� BUII.DING PERNIIT APPLICATION � _ ..,,. . FIRMLY , . .,m.. . . :. ., ,-. ¢ ADDRESS �-'-�`-f�� �j�o���- .��• ' APPLICATION � /� PERMIT ;� ��f� �P/C o DATE � �� 4.ti NUMBER # � APN LOT ��TRACT qTE � �� '��p ONST. GROUP p OWNER /���LYIfC.lCC[,�� fX p ADDRESS�� �E 20NING SETBACKS W FRONT � CITY _ /f�"�*d�✓ J� ijl7� TEL. .� �a RW ❑ APPUCANT TEL. REAR � � SIDE/SIDE STREET RW ❑ CONTRACTOR .�C.¢ .,'�.� 4G � SIDE p ADDRESS 2Z ct�.h T. � CITY _�`��GN✓ ZIP'��TEL. t PROPOSED USE �"r�' o ARCH/ENGJ � DESIGNER NO.DWEL. NO. NO. ADDRESS v� UNITS STORIES BEDROOMS � CITY ZIP TE�. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEA DECLARATION SFR/ADD/REM O I MEREBY AFFlRM UNDEfl PENALTY OF PEI�IURY THAT I AM EXEMPT FHOM TNE CONTRACTORS LI- GafBge/Cefp0lt W CENSELAWFORTHEFOLIOWINGREASON�SEC.7IXi1.56U51NESSANDPROFES510NSCODE:ANYCITYOR (n V COUNTYWHICHREIXIWESAPERMITTOOOiJSTRUCT,PLTER,IMFROVE,�EMOLISH,ORREPAIRANVSTRUG W NRE.PRIOH TO ITS ISSUANCE,ALSO REOUIHES 7HE APPLICANT FOR SUCH PENMR TO FILE A 516NED W PatiolDeck � STA7EMENT THAT HE OR SHE IS UCENSED PUHSUAN7 70 7HE PRONSIONS OF THE CONTqACTORS Lb � � CENSE UW(CHAPTER o(COMMENCINO WITH SECTIqJ 7000)OF DIVISION 30F THE BUSINESS AND Pq0- PooUSp& FESSqNSCODE)ORTHATHEORSHEISEXEMPTTHEflEFROMANDTHEBASISFORTHEALLE�EDE%EMP- (� TION.ANVYpLATIONOF3ECTON7o31.6BYANYAPPLICANTFORAPERMITSU6JECTSTHEAPPLICANTTO Z Re-Roof � A CIVIL PEN�LTY OF NOT MORE THAN F�VE HUNDRED DOLLARS(5500),): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAOESASTHEIRSOLECOMPENSAiION, CommefCia� - YAIL 00 THE WOPK,AND hIE STRUCTURE t5 NOT IKfENOED OR OFFERED FOR SALE(SEC.7044,BUSI� �J � NE55 AND PROFESSIONS CWE:7HE CANTRACTORS LICENSE LAW DOES NOT APPLV 70 AN OWNER OF � PHOPENiV Vh10 BUIIDS OR IAIPROVES THEREON,AND WHO DOES SUCH NbRN HIMSELF OR HERSELF OR K THIWUGHHISORHERONMEMPLOVEES.PROVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEDOq m O OFFERE�FOqSALEiF,HOWEVERi'HEBUIL�IN60RIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- � TION,THE OWNER-BUILDEF WILL HAVE THE BURpEN OF PROVINO THAT HE OR SHE DID NDT BU�ID OR IMPROVE FOil THE PURPOu^E OF SALE�. W ❑I,ASOWNEROFTMEPROPERTY,AME%CLUSIVELYCONTMCTINOWITHLICENSEDCONTRACTOqS {= TO CONSTRUCT TME PR0.IECT(SEC,7040,BUSINE55 ANO PROFESSIONS COOE:THE CONTRACTOqS U� V8II78110t1 ADJ.AREA W CENSEUIWDDESNOTAPPLYTOANONMEROFAPROPERNWHOBWLDSORIMPRDVESTHEREON,ANO � WFpCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOR(SILICENSEDPURSUANTTOTNECONTFiAP QUANTIIY DESCRIPTION FEE � TORS LICENSE UW.). - �IAM EXEMVT UNDER S�C, g.3 P.C.FOP THIS REASON Q 3 U � � ZZ DATE DWNER F� � W LICENSED CONTRACTORS DECLARATION -� � w _ I HEREBY AfFIqM UNDER PENALTY OF PEflJURY THAT I AM LICENSED UNDER FROYISbN50F CHAPTER � / ���.�p� � ` (� 9(CflA1MENCIN(�WITH SECTION 7000)OF OIViS!OIJ 30F THE BUSINESS AND PROFESSIONS CA�E,AND Z N'/ C- X MY UCENSE IS IN FULL FORCE AND EFFECT. � LICENSE CLAS+�S �'� LIC.NO._ T a Ar F�'����� _ V DATE�V�����'��� CONTRAC70R �"7 G�"'/ � W � WORKEHS'COMPFNSATION DECLARATION � � I HEREBY AFFIRM UNDER PENALTY OF PEIUURV ONE OFTHE FOI.LOWIN(i DECLARATIONS: Z � ___IHIIVEAMDWI AINACERTIFlCATEOFCANSENTT06ElP-INSUREFORWORKERS = COMP N.AS PflOVIDED BY SECTION 37ao OF THE LPBOR CODE,FOR THE PERPORMANCE U O O WORK FOR WHICH THIS PERA11715 ISSUE�. � W _IHAVEANDWILLMAINTAINWORKEflS'COMPENS IONIN5 CE qEWIR'c69Y5ECTION O 370o6FiHELAB E,FORTHEPERFOR C FT O RWHICHTHISPERMITIS � SSUED.MY W KE S'COMPEN ATION INS' AN A ICV NUMBERAPE� CONSTRUCTION �, CARRIEfl �� � PLAN REVIEW � POL�cY NUMBER_ ELECTRIC _ 4 � (iMl55K.'fpNNE�NDTBE00�✓YL.EfIDOFTiEPEF4NTiSR�RONE E� (51ao�ORLESS�. PLUMBING p, � Z I CEflTIF'/THAT W THE PEPfORMANCE OF THE WORK FOR HICH IS PE Ii IS ISSUEO,I MECHANICAL C� SNALLN07FMPLOVANYPERSONINANY4IANNERSOAS BECO SU ECTTOTHE (n WORNERS'CbMPENSATIONLAWSOFCALIFORN N REE I I OULDBECAME INSPECTION � SU&IECTTOTHEWOFKERS'COMPENSATION OV 10 �OOOFTHELABOfl ' • r y CODE,I SHALL FONTH ITH COMPLV WITH T ISSUANCE � SMIP p �ATE:����APPLICANT: J WAfiNINO�FAILURE TO SECURE WORKERS'COMPENSA RAGE IS LAWFUL,AND SHALL BE ENERGY PI _ �y SUBJECTANEMPLAYERTOCRIMINALPENALTIESANOCIVI ES NEHUNDREDTHOUSANO ENERGYP - I�� DOLLARS(5100.000).IN ADDITION TO THE COST OF COMPENSATION,OAMAGES AS PROVIOEO FOR IN q � SECTION 37oe Of THE UBOR CO�E,INTEREST,AND ATTORNEYS FEES. RETENTION F E __�"""---;'- - OCONSTRl1CTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBYAFFIRM UNDER PENALTV OF PERJURV THATTNERE IS ACONSTRUCTION�ENDMG AGENCY FOF THE PEHFOqMANCE OF THE WORK FOR WHICN THIS�EFMIT IS ISSUED(SEC.30W,CIV.G}. Z W iZ LENDER'S NAME -- - I— LENDER'SADORE55 w ICERTIFYTHATIHAVEREAOTVISAPPLICATIONANDSTATETNATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES \j�,� t �L`. � 1 AGREE TO COMPLV WITH ALL CITV AND CAUNTV ORDINANCES ANO STATE LAWS RELATING TO BNLDING � CANSTRUCTION.AND HEREBV AUT RIZE . RESENTAT'NES Of THIS COUNTV TO ENTEfl UPON THE Z ABOVE-MENTbNEDP0.qPERTV I ' ,T NPURPOSES. COMMENTS � �/� � m PEflMITTEE N � -� 7-�/ ,� , � SIGNATURE DF P I7T DATE — s � = RECPT.NO. PAID BY ' VALIDATION ~ WHITE—Deparlment Copy,YELLOW—Finance Copy.PINK—Assessor Capy,GOLDENRO�File Copy.GREEN—Ap�dicanNs Copy : ..�: .,,.,.. ... .:..... ...y..-... :,.;.., r� . �.i .r,:�... ,4. ..�, . ... . � , . ,.�, ..,, .,. . .. , .. � . ,,. .. ., , .. . .. .. �. . ,. , v . . _ .... ���� `�'�� �4:�����`�� � _. ��+��������� ������� � �_,: <<„ .., :..,_.. . 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