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HomeMy WebLinkAbout17388 (26) _ � �...� _ �� CIT�I OF DIAMOND BAR ',,,_,f���� �,r ---� -- DEPAR'I'MENT OF COI�'IM�7NITP&DEVELOPMENT SERVICES I `.-' ���. 21825 8.Copley Drive 9 (909)860-3195 Fax(909)861-3117 PRE$$ ''°%v�y'��' BUILDINGPERMYTAPPLICr�iTION FIRMLY � JOBSITE APPLICATION ) ' �� �-1 PERMIT• P/C o ADDRES53HN7 �/x,�Ld✓l �I � �i DATE 1 NUMBER�� # � ISSUE �° TYPE OCC .- qPN LOT TRRCT DATE � I J I CONST. GROUP p OWNER � W� C� LL ADDRESS.3y i 20NING SETBACKS � CITY a ZIP TEL�SYo�D�/I �EORT RW O APPLICANT TEL.�.�1.°� SIDE/SIQE STREET RW ❑ a CONTF2ACTOR SIDE ❑ ADDRESS � CITY ZIP TEL. PROPOSED USE 7P.�s1" � - O � iY i On "------a S' 3na P S �.�t o ARCHlENG/ —T iz DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFR/ADD/REM � I HEREOY AFFIRM UNDER PENALiY OF PERJURV THAT I AM IXEMPT FROM THE CONTRACTORS�I- G8f89B/CdfPOff W CENSEL4WFORTHEFOLLOWINGREASON(SEC.7037.SBUSINESSANDPROFESSIONSCODE:ANYCI7YDR (n _ U COUNTYWHICHREQUIRESAPEAMI7TOCONSTRUCLALTER,IMPROVE,DEMOLISH,ORfiEPAIRANVSTRUC- W Pdtio/DeCk W TUFiE,PRIOR TOJTS ISSUANCE,AL50 REOW RES THE APPLICANi FOR SUCH PERMIT TO FlLE A SIGNEO W � STATEMENT THAi HE OR SHE IS LICENSED PUPSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE LALV�CHAPTER 9(COMMENGNG WITH SECTION 7000)OF DIVISION 3 0F THE 6USINESS AND PR0- � POOIJSPd FESSIONS CODE)OR THAT HE OR 91E 13 EXEMPTTHEflEFROM AN�THE BA515 FOR THE ALLEGED E%EMP- � TION.ANYVIOLATIONOFSEGTION7031.50YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACIVIL ALTYOFNOTMORETHANFIVEHUNDRED�OLLARS(E5o0].): 0 ASOVJNEROFTHEPROPERTY.ORMYeMPLOYEESWITH:WAGESASTHEIRSOLECOMPENSATION, 0 COmmOfCial � z WILL�O THE WORK,AND THE STRIICTURE IS NOT MTENOED OR OFFEREO FOfl SALE(SEC.7044,9USi- J �, NESS AN�PROFESSIONS CODE:THE CONTRAC70RS LICENSE LAW DOES NOTAPPLV TO AN OWNER OF � .PROPERTVWHOBUILOSORIMPROVESTHEREON,At�IDWHO�0ES5UCHWORKHIMSELFORHERSELFOR m � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMEN�SARENOiIMENDEDOa Q .OFFERE�FOFSALE.IF,HOWEVER,THEBUI�DINGORIMPROVEMENTISSOL�WITHINONEYEAROFCOMPLE- ��. �TION,THE OWNER-BUILDER WILL HAVE 7HE BUN�EN OF PROVING THAT HE Ofl SHE OID NOT BUILD OF � IMPROVEFORTHEPURPOSEOFSALE). ❑I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSEO CANTRACTORS ' �" TO CONSTRUCTI'HE PROJECT(5EC.7a44,BUSINESS AN�PROFESSIONS CODE:THE CONTRACTORS LI- ADJ.AFIEA W CENSElAW�OESNOTAPPLVTOANOWNEFOFAPROPERTVWH06UILD50RIMPROVESTHEREON,AND . ��,, WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)UCENSEDPURSUANTTOTHECONTRAC- � pN DESCRIPTION FEE Y TORS LICENSE LAW.). � J o ❑I AM EXEMPT UNDER SEC. 6.&P.C.FaR THIS REASON � U � �*+/S� � WNER U W � LICENSED CONTRACTORS DECLARATION W � IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTEFi � d 9�COMMENCINGWITHSECTION7C00)OF�IVISION30fiHEBUSiNESSANDPRDFE5510N5CO�E,AND Z X MV LICENSE IS IN FULL FORCEAN�EFFECT. m W' � LICENSE CLASS LIC.NO. � U DATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNDERPENALNOFPERJURYONEOFTHEFOLLOWINQDECLARATIONS: U (J� a 0 _IHAVEANDWILLMAINTAINACERTiFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ z COMPENSATION,ASPROVIDEDBYSECTIIXJ370oOFTHEIABORCODE,FORTHEPERFOFMANCE U ¢ OF THE WORK FOR WHICH 7HIS PERMIT IS ISSUED. � � W I HAVE AN�WILL MAINTAIN WOFKERS'COMPENSATION INSURANCE,AS REQUIRED BY SEC710N � ��. Q� 370o OF THE LABOR CODE,FOR THE PEflFORMANCE OF THE WORK FOR WHICH THIS PEPMITIS ISSUE�.MYWORKERS'COMPENSAT70NINSURANCECARRIERANOPOLICYNUM6ERARE: CONSTRUCTION � J j� cnRa�eA � � PLAN REVIEW � POLICYNUMBER ELECTflIC Q � (iHISSECTIONNEmNOTOEOJMPLEfEDOFhiEPERMRISFORONEHUNDREDDJLlAR5�S10�ORLE55). PLUMBING Z, ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFOFWHICHTHISPERMITISISStJED,I MECHANICA� (} SHALL NQT EMPLOY ANY PERStlN IN ANY tdANNER SONS TO BECOMc SUBJECT TO THE � � WORHERS'CONPENSATICNLAWSOFCALIFOflNIA,ANDAGREE7HATIFISHCULDBECOME INSPECTIONFEE � = SUBJECTTOTHEWO(iKERS'COM?ENSATIONPROVISIONSOFSECTION37ooOFTHELABOfi t�� COf1E,I SHALI FORTHWITH COMPLY WITHTHOSe PROVISIONS. �SSUANCE �� SMIP • ��_ d DATE: APPLIGANT. , J WARNING.`FAIWRE TO SECURE WORKEFIS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE ENERGY P/C ' �. SUBJECTANEMPLOVERTOCRIMINALpENALTIESANDCIVILFINESUPi00NEHUNDREDTHOU5AN0 ENERGYPERMIT DDLL4RS(51 ao,aoOJ,IN ADDITION TO THE COSi OF COMPEN&ATION,DAMAGES AS PROVIDED FOR IN J SEGTION3la80FTHELA80RCODE,INTEREST,ANDATTORNEY'SFEES, RETENTIONFEE: � � CONSTRUCTION LENDING AGENCY pRE-AL7 FEE: O � �� IHEREBYAFFIRMUN�ERPENALTVOFPERJUftYhiATTHERCISACONSTRUCTIONLENDINGAGENCY . FORTHEPERFOFMANGEOFTHEWORKFORWHICHTHISPEFMITISISSUED(SEC.3a9],CIV.C.). Z W 2' LENDER'S NAME � � F—� LENDER'SADDRESS , w ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �5� � IlGFEETOGOMPLYWITHALICITYANDCOUNTYORDINANGESANDSTAiEL4W5RELATWGTOBUIL�IIfG .�� CONSTRUCTION,ANDHEflEBVAUiHORIZEREPRESENTATIVe50FTHI5COUN7YTOENTEHUPONTHE Z ABOVE�MENTiIXJEO PROPERTYFOR INSPECTION PURPOSES. 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