HomeMy WebLinkAbout17096 (23) � _ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES 21$25 E.Copley Drive "�`� � (909)860-3195 Fa�c(909)861-3117 PRESS '��`�•Y��� BUILDING PERMIT APPLIGATION FIRMLY � JOBSITE i A_ APPLICATION PERMIT +I P/C o ADDRESS����T. �1-�u�/�j�/�w�� �__ DATE J����, NUMBER��Y,1�`_'°'� # � APN LOT TRACT ISSUE TYPE OCC DATE CpNST. GROUP p OWNER T " ADDRESS 'Z- ZONING SETBACKS z CIN��� ZIP , TEL. FRONT RW O o APPLICANT TEL. SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR � � SIDE ❑ ADDRES8. • PROPOSED US � CIN ZIP TEL. �' 1 o ARCH/ENG/ �z DESIGNER NO.DWEL. • NO. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � c� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDEFi DECLARATION SFR/ADD/REM O p I HEPEBY AFFIRM UN�ER PENPLiY OF PERJURY THAT i AM EXEMPT FFOM THE CONTRACTORS�I� G9f2gB/CefPOR W CENSELIWFORTHEFOLLOWINGPEASON(S6C.7031.59USINESSANDPROFESSIONSCODE:0.NVCINOR (n U CWNTVWHICHREDUIHESAPERMITTOCONSTfiUC7,ALTER,IMFROVE,DEMOLISH,ORREPAIRANYSTPUG W TURE,PFIOR TO ITS ISSUANCE,ALSO FEOII!RES 7H"e APPLICANT FOR SUCH PERMIT 70 FILE A SIGNe'D � Patio/DBCk STATETAENT THAT HE OR SHE IS LICENSEO PURSUANT TO TNE PROVISIONS OF THE CONTRACTORS LI- � CENSE LAW(CHAPiER B(COMMENCWG WI7H SECTION 7000)OF DI�ISION 30F THE BUSINE55 AND PRO- � Pool/Spa FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEOEXEMP- (� � TION.ANYVIOLATIONOFSECTION7031.58YANVAPPUCANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z Re-Rocf A CIVIL PENALN OF NOT MORE THAN FNE HUNDRED DOUARS(5500).): - � ❑I,ASOWNEROFTHEPROPEAr',ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION. ❑ COfnmOfCial Z WILL�O THE WORK,AN�THE STRVCTURE IS NOT INTEN�E�OR OFFERED FOR SALE(SEC.7a46,BUSI- J � NE55 NND PROFESSIONS COOE:THE CONTRFCTORS LICENSE LAW OOES NOT APPLV TO AN OWNEP OF � PROPERTY WHO BUILDS OR�MPqOVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OP � THqOUGHHISOflHEROWNEMPLOYEES,PROVIDEDTHATSUCHiMPROVEMENTSARENOTINTENDEDOR m W OFFEREOFORSALE.IF,HOWEVER,THEBUILOINGORIMPFOVEMENTISSOLOWITHINONEVEAFIOFCOMPLE- � TION,THE OWNER�BUILDER WIIL NAVE THE BURDEN OF PROVING TMAT HE O(i SHE DI�NOT BUIID OR Z IMPROVE FOR THE PURPOSE OF SALE). �� OI,ASOWNEROFTHEPROPEFTlY,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTFACTORS TO CANSTRUCT THE PROJECT(SEC.7oa4,BUSINE55 AND PROFESSIONS CODE:THE COMRACTORS LI- VeIUfl110 ADJ.AREA = CENSELAWDOESNOTAPPLY70ANONMEROFAPRO�ERTYWH09UILDSORIMPROVESTHEFEON,AND � WFiOCONTRACTSFOPSUCHPROJECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECC{JTRAC- QUANTITV DESCRIPTION FEE Y TORSUCENSELAW.). � O I AM EXEMPT UN�ER SEC. R.8 P G FOR THIS REASON U � l_L � DATE OWNEF � W ¢ LICENSED CONTRACTORS DECLARATION �j 2 I HEREBY AFFIRM UNOER PENAITY OF PERJUPY TH0.T I AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9(COMMENdNG WITH SECTION7oo0J OG DIVISION 30F THE BUSINESSAND PROFESSIONS CODE,ANO Z 1X MY LICENSE IS IN FULL FOnRCE AND EFFECT. m � LICENSE CLASS v IIC.NO.��I� � 1— ��_///ppp M � � J DATE� ��/ CONTRACTOR d:. W / I � WORKERS'COMPENSATION DECLARATION -�' ¢ � I NEREeY AFF'��RM UNOER PENALTV OF PERJURY ONE OFTHE fOLLOWING DEC4ARATIONS: V � Z 4� � IHAVEANDWILLMAMTAINACERTIFlCATEOFCONSENiTOSELFINSUREFOPWORKERS' 2 Z CAMPENSATION.A&PROVIDEDBY&ECTION37ooOFTHELABORCODE,FORTHEPERFORMANCE U Q OFTHEWORKFORWHICHTHISPEFMITISISSUEO. � 0 w _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBVSECTION Q 3�OOOFTHELABORCADE,FORTHEPERFORM1iANCEOFTHEWORKFORWHICHTHISPERMITIS I�V�O ISSUED.MYWOftKERS'COMPENSATIONMSU NCECARRIERANOPOUCYNUMBERARE: CONSTRUCTION ll ¢ CARflIER �� ��hr� P�N REVI�W 7 0 POLICYNUMBER _��QI ELECTRIC d � (IHISSECTK)NNEmNOTBECOMPLE�EDOF7HEPEPIMISF7RDNEHUWREDDOLLAFSrytW!ORLESS} PLUMBING Z ICEFTIFVTHATINiHEPERFORMANCEOFTHEWORKFOFWHIqiTH'SPERMITISISSUED,1 MECHANICAL (� SHALL NOT EMPLOYANV PERSON IN ANV MANNER SOAS T09ECOME Sl1BJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDA4REETHATIFISHOULDDECOME INSPECTIONFEE �--. �— SUOJECT T0 THE WORKERS'COMPENSATION PR�VISIONS Of SECTION 9700 OF TNE LABOR �� �y� � CODE.I SHALL FORTHWITH COMPLY WITH THPSE PR VISI S. ISSUANCE �'.� v�+ 0 y^� p DATE�����.. APPLICANT. A 1 SMIP � � W ENERGY P/C � WARNIN :GAIWRETOSECUREWORHERS'COMPENSATIONCOVERAGEISUNUIWFUL,ANOSHALLBE � SUBJECTANEMPLOVEPTOCRIMINALPENALTIESANDCIVILFlNESUPTOONEHUNOREDT40USAND ENERGYPERMIT DOLLARS(f1�O.00D).IN ADDITION TO 7FiE COST OF COMPENSATpN,DAMAGES AS PROVIDED FOR IN J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � � CONSTRUCTION LENDING AGENCY pRE-AL7 FEE: � INEREBVAFFIRMUN�ERPENALTYOFVERJUF�THATTHEHEISACONSTRl1CTIONLEN�INGAGENCY FOR THE PERFORMANCE OF 7H[WORK FOR W4ICHTH�S PERMITIS ISSUED(SEC.309],CIV.C.). Z W -- � LEN�ER'SNAME F'— LEN�ER'SADDRESS w ICERTIFVTHATIHAVEREADTHISAPPLICATIONANDSTATF.THATTHEABOVEINFORMA'IONISCORFECT. TOTAL FEES � � I AC+F,EE TO COMPLV W17H A�L CITY ANO COUNTY OPDINANCES ANO STATE LAWS RELATING TO eUILDING � CONSTRUCTION,AN�HEREBYAUTHOqiZEREPRESENTA�'IVESOFTHISCOUNTVTOENTERUPONTFE Z A80VE�MENTIONED'PRfOPER'Y FOP INSPECTION PUqPOSES � / COMMENTS � �����---------����/�/" J � Ll�� m PERMITTEE NAME WT � r �-tL�D1 � SIGNATUREO ftMl DAT� = RECPT.NO. 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