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HomeMy WebLinkAbout11151 (5) � —�``--- CITY OF DIAMOND BAR �t'� �� � COMMUNITY DEVELOPMENT DEPARTMENT� � 21660 E.Copley Drive Suite 190 ' � PRESS � (909)860 3195 Fax(909)861 3117 � "'y""�` BUILDINGPERMl'1'APPLICATION FIRMLY �, BSITE �y r APPLICATION PERMIT � P/C DDRESS / �Z � f�IrC��_� �. DATE �j�—NUMBER '��� Ik o� - �- ISSUE���L " TYPE OCC i APN LOT—�,' TRACT DATE CONST. GRQUP I p WNER MINDY �� — -- ZONING SETBACKS " DDRESS�!2 S ����, ' QCITY r�l11��2y(�14IZZIP 917�� TEL.��Q�I O 3 FRONT RW ❑ PPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ Q, CONTRACTOR SIDE ❑ �` ADDRESS ROPOSED USE – IS W�aVc� �7 0 CITY 21P TEL. � ( L �- �JL . ` f t c,- w ARCH/ENG/ p� ' wDESIGNER NO.DWEL NO.. N . ��� �,; ADDRESS UNITS STORIES BEDROOMS _= CITY ZIP TEL � _- -. 'pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUAT�ON ` �-, � ���OWNER-BCILDER�ECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PENALTY OF PEFJURY 7HAT I AM EXEMPT FROM THE CANTRACTORS LI� � G8l8(JB/CafpO(1 � �W- CENSELAWFORTHEFOLLOWINGR[ASON(SEC.7091.50USINESSANDPROFESSIONSCODE:ANYCITYOR � (/� � � U -COUNTVWHICHREOtJIRESAPERMITTOCON5TRl1CT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTFUC W pyS10/DOCk Z'- 'TURE.PFIOR TO IT.ISSUANCE,ALSO flEQUIRES THE APPLICANT FOR SUCH PEftM1T TO FILE A SIGNE� ' W� STATEMENT THA7 HE OR SHE IS LICE�SED PuqSUANT TO TNE PROYISIONS OF THE CANTRAC70RS ll - -W � CENSEIAW(CHAPTER9(COMMENCINGWITHSECTION7a0a)OFOIVISION3DFiNEBUSWESSANDPRO� � PODVSP3 - �� 0 FESSIONSCObE�ORTHATf{GOfiSHEISEXEMPTTHEREFflOMANpTHEBASISFORTHEAlLEOEDEXEMP- ., (!f U_ TION.ANVVIOLATIONOFSECTION7031.58VpNVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO � RB-R00} QO � ACIVII.PENALTYOFNOTMORETHANFIVEHUNDFEDOOLLARS(SSoo).): p ❑I,pSOWNEFOFTH&PROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIflSOLECOMPENSAT104 Commercial �-- -�� Z WILL DO THE WORK,'AND THE STRUCTURE IS NOT IMENDED Ofl OFFERED FOR SALE�SEC.7o44,BUSI J : NESS AND PROFESSIONS CADE:TNE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF �._ - � PROPERTYWHOBUILUSORIMPROVESTHEFEON,ANDWHODOESSUCNWORKHIMSELFOflHEFSELFOR � - � THROUGHHISORHEROWN[MPLOYEES,PftOVIDEDTHATSUCHIMPROVEMENTSARENOiINTEN�EbOR m ' � OFFEFEDFORSht.F.IF,HOWEVER,THEBl11L�INGOflIMPROVEMENTI550L�WITHiNONEYEAflOFCOMPLE� _ . � TIDN,THE OWNER-BUIlOER WILL HAVE THE 6UflOGN OF PROVING THAT HE OR SH[�ID NOT BUIID OR � IMPROVE FOHTHE PURPOSEOF SAI.�. W ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCONTPACTIYGWITHLICEN3EDCONTflAC70PS ` �y � TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS ANO PROFESSIONS CODE:THE CONTRACTOflS LI- �- dlUBllOfl JOGO ADJ.AREA W CENSEIAWDOESNOTAPPIYTOANOWNEROFAPROPERTYWHOeUILDSORIMPHOVESTHEREON,ANO � WHOCANTRACTSPoRSUCHPRQIECTSWITHACONTRACTOR(S)LICeNSEDPURSUANTTOTHECONTMG � QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.}. ` _ � ❑I AM EXEMPT IINDEP SEG B,&P.C.FOR THIS REASON '� �Q � v � �, � � DATE F OWNER U Z W. � �. LICENSED CONTRACTORS DECLAFATION W �� [[ -I HEREBY AFFIRM UNDE(7 PENALTV OF PEflJURYTHAT IAM LICENSED UNDEfl PROVISIONS OF CHAPTER � d, '9(COMMENCING YlITH SECTION�OOD)nF�NISION 3 OF THE 81151NE5S'AND PROFESSIONS CADE.M1D z �X MY LICENSE IS IN FULL FORGE AND EFFECT. � m � 0 � � � LICENSE CLASS LIQ NO. J �_ U DATE CONTRAC70R � � -- a , W �� WORKERS'COMPENSATION DECLARATION a = U � IHEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHF.FOLfOWINGDECLARATIONS: � Q � IHAVEANOWILLMAINTAINACERTIfICATEOFCONSENTTpSELF�INSUREFORWORKERS' _ CAMPENSATION,ASPROVIDEDBVSECTION37�OOFTHELABORCODE,FORTHEPEPFORMANCE U ¢ OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�. � � w _IHAYEANOWILLMAINTAINWOPKERS'COMPENSATIONINSURANCE,ASREQUIRE09YSECTION ' Q 370o OF THE LABOR CODF,FORTHE PERF(1RMANCE OF THE WORK FOR WHICH THIS PERMIT IS �� � ISSUED.MYWOPKERS'CAMPENSATIONINSURANCECARfiIERANDPOLICYNUMBE{tARE: CONSTRUCTION O �S �-- jcneaiER__ PLAN REVIEW � Zroucvrvun+eea ELECTRIC _._____.,..___ ' 4 � (I}iLSSECTiONNEmNOTBE�PLEfE�OFTHEPEMMISWRONEMJWREDDOLLAHS(510�OR1E55). . PLUMBING Z I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK f0(1 WHICH THIS PERMIT IS ISSUED,I MECHANICAL � SHALLNOTEMPLOYANYPERSONINANYMANNERSOAS70BECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOAGFEETHATIFISHOULDOECOME INSPECTIONFEE SU&IECT TO THE WORKEFS'COMPENSATION PROVISIONS OF SECTIOY 3700 OF THE LABOR �^� � CA�E,ISHALLFORTHWITISCOMPLYWITHTHOSEPftOVi$IONS. ISSUANCE ���lJ p DATE: APPLICANE SMIP + �� J- ENERGY P/C WFRNMGFAILURETOSEGUFEWOflKERS'cOMPENSATIONCOVEf1AGEiSUNLAWFUL,ANDSHAILBE — — -- - . � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDqVILFMESUP700NEHUN�REOTHOUSAND ENERGYPERMIT - �OLLAHS(57o0,006),INA�DITIONTOTHEGOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN J� SECTION 3708 OF THE LADOF CADE,INTCREST,AND ATTORNEY'S FEES. RETENTION FEE: � � OCONSTRUCTION LFNDING AGENCY pRE-ALT FEE � � � I HEPE6Y AFFIftM UNDEfl PENALTY OF PERJURV THAi THEPE IS ACONSTRUC710N LENDIt:G AGENCY - n- FOR THE PERFORMANCE OI-THE WORK FOR WHIGH TMIS PERMIT IS ISSUE�(SEC.3097,CIV.Gj. Z W = LENDEfi'S NAME ——. _ f- LENOER'SADDfiESS � I CERTIFV THAT I HAVE FEA�THIS APPLICATION AND STATE THATTHE ABOVE WFOFMATID�IS COPPECT, TOTAL FE ES �� �� w I AGREE TO COMVLY WITHALL CITY AN�GOIJNTY ORDINHNGESANO STATE LAWS RELATMG TOBUILDING � CONSTFIUCTION,AND HEp[BV AUTHORIZE REPRESENTAT!VES OF THIS COUNTV TO ENTER UPON THE - - ' - " zA60VE�MENTIONFDPROPERTYFOHINSPECTIONPUHPOSES. COMMENTS � � M t N.D C ��I Q �P MITTEE�NT)` � � /� _ . ti � Z l � � IGNATURE OF PERMITTEE DATE �� -'- = RECPT.N0. 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