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HomeMy WebLinkAbout14843 _ � ���.�:� � _`�� CITY OF DIAMOND BAR G(�`��}�ry� . DEPART?:ZENT OF COMMUNITY&DEVELOPMENT SERVICES �:�'V L � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ����'� BUII;DING RMYTAPPLICATION FIRMLY � __- :. . .. _ _. . .,.A o� JOBSITE ���� ��� DATECATION ' UU NU BER � #,C ADDRESS $ ISSUE �^OI TYPE OCC APN LOT TRACT DATE 11U CONST. GROUP SOWNER p ADDRESS �g.� ZONING SEfBACKS W CITY � ZIP .�E`L. FRONT RW ❑ �j APPLICANT EL. REAR ❑ � SIDElSIDE STREET RW ❑ � CONTRACTO SIDE ❑ ADDRESS � CITY ZIP TEL. PROPOSED USE o ARCH/ENG/� � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O I HERE9Y AFFIRM UNDEH PENILLTY OF PE0.0.1RY THAT I AM EXEMP7 FROM THE CONTRAC7oR5 LI- G8f2[J8/CdfpOf[ W CEN5EUWFORTNEFOLLOWINGREASON(SECJ031.6BUSINESSANDPROFESSIONSCODE:ANVCITVOR (n C� COUNTVNMICHREOUIRE6APERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W Pe�iO/DBCk W TURE,PRIOFl TO ITS ISSUANCE,�LSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FllE A SIONED W STATEMEM THAT HE OR SHE IS LILENSED PURSUANT TO TME PROVISIONS OF THE CONTRACTORS U- � CENSE lAW(CHAPTER 9(COMMENCINO WITli SEC7ION 7aoo)DF DIYISION 3 OFIHE BUSINESS ANO PRO- � POOUSPB PESSIONS COOE)OH 1HAT HE OH SHE IS EXEMPT THEREFHOM AND THE 6A515 FOF THEALLEGED E%EMP- TION.ANYVIDt.ATI0NOF5ECTI0N7o31.58VANYAPPUCANTFOHAPERMIiSU&lECT57HEAPPLICANTTO Z RB-Ro01 � ACMLPENALTYOFNOTMORETHANFNEHLNDREDDOLLARS(SSao).�: � ❑tASOWNEROFTHEPHOPEHTY.ORMYEMPLOVEESWITHWA0ESA5THEIRSOLECOMPENSATION, � CommefCial - NIILL DO THE WORK/WD THE STRUCTUiiE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704a,BU51- J � NESS AND PpOFE5S10NS CODE:THE CONTRACTORS LICEMSE LAW OOES NOT AVPLV TO AN OWNER OF j PqOPERTY VhlO BUILDS OH IMPROVES THEREON,AND WHO�OES SUCH WORIC HIMSELF OR HERSELF OR � THRd1f3HH130RHERONMEMPLOVEES,PROVIDEDTFWTSUCHIMPROVEMENTSARENOi1NTENDE00R m Q ,OFFERWinRSALEIF,HOWEVER,iHEBUILDINOORIMPROVEMENTI550LDWITHINONEVEAROFCAMPLE- z TION,THE OWNER�U0.DER WILL HAVE THE BURDEN OF PROVING THAT HE oR SHE OID NO7 BUILD OFi = IMPfqVE WqTHE PURPOSE OF SALE). �y,� ❑I,ASDNMEROFTHEPROPEHTY,AME%CWSIVELVCANTRACTMGWRHLICENSE�CAN7RACTORS � TO CONSTHUCTTHE PROJECT�SE0.loH,BUSMESS ANO PROFESSIONS CODE:THE CONTRACTORS LI- Valu2tion ADJ.AREA W CENSELAWDOESNOTAPPIVTOANOWNEROFAPROPEPT/WHOBl11LDSORIMPROVESTHEiiE�N,ANO Z WFIOCONTRACT3FORSUCHDQQIECTSWITHACONTHACTOR(5)UCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORS LIC6NSE IAW.�. ❑I AM EXEMPT UNDER 9EC. B,8 P.G FOR THI3 REASON Q 3 � � � DATE OWNER U � W LICENSED CONTRACTORS DECLAFiATION -� � w I HEREBV AfFIRM UNOER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � d B(COMMENCINOWITHSECTION700o)OFDIYISION30F7HEBUSINESSANDPROFESSIONSCODE,AND z `�� MY UCENSE IS IN FULL FOHCE AND EFFECL _ 1p m C � LICENSE CLASS ��„�'7 LIC.NO. v / � � �19�^ry " V DATE �� � CONTRACTOR d ���� W a� WORKERS'COMPENSATION OECLARATION -� a NI HEREBV AFFlFiM UNDEil PENALTY OF PERJURY ONEOF THE FOLLOWING DECLAHATIONS: Z � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSl1REF-0RWORNERS' _ CdAPENSATION,ASPROVIDEDBVSECT10N3/ooOFTHEU�80RCODE,FORTHEPERFORMANCE U Q �THE WORK FOR WNICH THIS P�RMI71S ISSUED. � � _I HAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSUPANCE,AS REDUIRED 8V SECTION QQ 3700 OFTHE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOP WHICH THIS PERMIT IS ISSUED.MYN'ORK RS'COMP SAT INSURANCECARRIERAN�PoLICYNUMBEHARE: CONSTRUCTION Q � CARRIER PLAN REVIEW � POUCYNUMBER__�.l i� � ELECTRIC 0 (fHISSECfIGWNE�FpTBE�LEfEDOFTHEPERrYfISFORONEIiUPDftED00lJ.ARS(SiW)ORLESS} PLUM6ING � Z 1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANICAL '�j 9HALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO TNE � WOflKERS'C NSATIONLAWSOFCALIFORNIA,ANDAOPEETHATIFISFIOULOOECOME INSPECTIONFEE S SU&lE TO T WORKERS'COMPENSATI � OVISIONS OF SECTION 37aa OF TH OR ^� f CA H O W17HCOMPLYWITH OS OVISIONS. ISSU P��f � � SMIP p DATE: APPLICANP. J WARNINO:FAILURETOSECUREWOf1KEFS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHAILBE ENERGYP/C A�(] 1 wT �sE��R� LL SU&IECTANEMPl.OYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGVPERMIT ���`��� ¢ OOLURS(ito0,0a0),IN ADDITION TO THE COSTOF COMPENSATION.DAMAGES AS PROVIDED FOR IN p /'� y�,-( 7p�$ 7�,( SECTION37080FTHEUIBORCOOE,MTEREST,ANDATTORNEY5FEE5, RETENTIONFEE: �l�ll�ilpt�iNL�4�- ��C � OCONSTRUCTION IENDING AGENCY PRE-ALT FEE: 7�����d g�„��,.�.31����'1$� � INEREBYAFFlFMUNDERPENALTVOFPERJURYTHATTHEREISACO45TRUCTIONLEN�INOAGENCY FOR THE PERWRMP.NCE OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV.C.). . Z w � LENDER'S NAME F— LENDER'SADDRESS � ICERTIFV7HATIHAVEREADTHISAPPLICATIONAfJDSTATETHATTHEABOVEINPoRMATKKJISCORRECT. TOTAL FEES ` � 1 A6REE TO COMPLY W1TH ALL CITY AND COUNTY OR�INAN ES AND STATE LANS REUTING TD BUIIDING '] +� � CONSTRUCTION,ANOHEREBYAUTFIORIZEREPRESENTATI SOFTHISCDUNTYTOENTERUPONTHE n�l,/ rv,/i� ��T LaY�/ �Z✓' Z ABOVE�MENTIONE�PROPERTV FOR INS crwN PURvos s• COMMENTS b�k F � .-.r� J m Q PEHMITTE NAM (PRI � y SIONATUPEOFPE EE = RECP2 NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Financas Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy .,,,..,q� r.«'�rz, ,. �Li� , �`i.7:�; . ...�.,:.,.' � •��'; e.:. ^��..,,.., � , . .- , .. ' . �.5+` . , `5f.,� „ � . ... .. .. . _,_ ,. . ..... .., ... . . ��;��� �� ��:��� �� . i Nk ti,., ..:•, a r�: �, . �� �� �'a L,� � � � .n. 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