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HomeMy WebLinkAbout16046 � _ ��VY"'�� ' _�� CITY OF DIAMOND BAR G U/���U DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��/ I } � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS `'`�� � BUII.DING PERMIT APPLICATION FIRMLY � �9 - . ,•.. _ . . . o� JOBSITE �p� /''� 'i..��^�,'��� APPLICATION � �����i NUMBER�� #/C ADDRESS (C�C.� j ��E�� DATE � ISSUE TYPE OCC -- APN OT TRA T DATE CONST. GROUP p OWNER � u' ADDRES ZONING SETBACKS Z CITY �IP TEL. FRONT pyy ❑ g APPiICAN"f � '� ,� ��, REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR ' SIOE ❑ p� ADDRESS _ � CIN ZIP���1'EL. ,L PROPOSED USE o ARCH/ENG! �z DESIGNER Np.OWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlREM O p I HEREBY APFlRM UNDER PENALTV OF PERJUHY THAT I AM EXEMPT FPOM THE CANTRACTORS LI- Garage/Cerport W CENSELAWiORTHEFOLLOWINaRF.ASON(SEC.7o37,5B11SINE5SANOPROFE5510NSCO�E:ANYCI7V�R (n U COUNTVWHICHREdIIIRESAVERMITTOCONSTRUCT,ALTER,�MPROVE,DEMOLISH,ORREPAIRANVSIRUC- W pyli0/DBCk z TURE,PRIOR TO ITS ISSUANCE,ALSO REDUIRES THE APPLICAM FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll- W � CENSE LAW(CHAVTER 9(COMMENCINO W1h15ECTION 7000)OF DIVISION 90F THE BUSINESS AND PR0- V"' POOUSpfl FESSqNS COOE)ORTHATHE Ofl SHE IS EXEMPTTHEREFFOM AND THE BASIS FOfl THE ALLEOED EXEMP- � TqN,ANYVKKATIONOFSECTION7031.69YFN7APPLICANTFORAPEflMITSU&IECTSTHEAPPUCANTTO Z Re-Root � ACML PENALTV OF NOT MORE THAN FIVE HUNDRED OOLUIRS(55ooJ,): � ❑I,A504RJEHOFTHEPFOPER'fY.ORMVEMPIOYEESWITHWAGESASTHEIRSOLECOMCENSATION, C] Commercial - NfILL DO TNE WORI(.ANO THE STRUCTURE IS NOT MTENDEO OR OFFEREO FOR SALE(SEC.7odd,BUSI- J � NESS AND PROFESSIONS COOE:h7E CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ? PROPERTY VhlO BUILUS OR IMPROVES THEREON,ANO WIiO DOES SUCH WORK NIMSELF Oif HERSELF OR d iHROUGHHISOHNERONMEMPLOYEES,PROVIDE07NATSUCHIMPFDYEMENTSARENOTINTENDFAOR m QOFFERmFORSALEIF,HOWEVERTMEBUILOINaORIMPROYEMEMISSOIDWITMNONEYEAROFCAMPLE- Z TpN,THE OWNER�BUILDER WILL HAVE THE 6URDEN OF PROVING THAT HE OR SHE DIO NOT BUIID Oft � IMPFpVE FOR THE PUflPOSE OF SALE�. �y,� ❑I,ASOWNEROFTHEPROPEHTV,AME%CLUSIVELYCONTRACiINGWiTNIICEN5E000NTRACTORS � TO CONSTRUCT THE PRO.IECT(SEC.70l4,BUSINESS AND iHOFESSIONS CODE:7HE COMRACTORS LI- ValUB[ion ADJ.AREA W CENSE UW DOES NOTAPPLY TOAN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEfiEON,AND � WFIOCONTRACTSFOfiSUCHPRQIECTSWITHACONTRACTOF(5)LICENSE�PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORS LICENSE UW.). 0 �IAM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON v � � �=' OATE DWNER U Z W ¢ UCENSEO CONTRACTORS DECLARATION W OC I HEPEBV AFFIRM UNDER PBJALTV OF PERIURY THAT I AM LICENSED UNDER 7ROVISIONS OF CHAPTER � r ` p� 9(COMMENCINOVYITHSECTqN7000jOFDIVISION30FTHE9USINESSAN�PROFESSIONSCODE,AND Z X MV UCENSE IS IN FULL FORCEAND EFFECT. �ry /� �— Q LICENSE CLASS LIC.NO.�� i � N . � ~ �+ J V DATE CONTRACTOR ` d W � WORKERS'COMPENSA710N DECLARATION Q = U � I HEREBY AFFIRM UNDER PENAL7Y OF PERIURY ONE OFTHE FOLIAWING DECLARATIONS: l� ¢ 0 IHAVE���JJJ777DWILLMAINTAINACERT�FICATEOFCANSENTTOSELF-INSUREFORWORKERS' 2 . � _JQ�SATqN,AS PROVIOE�8Y SECTION 3700 OF TNE LAHOR CADE,FOR THF.PF.FiFORAAANCF �U O E WORK FOR WHICH THIS PERMIT IS ISSUED. � 0 W I HAVE AND WILL MAINTAIN WORKEflS'COMPENSATIDN INSURANCE,AS REQUIFED BY SECTION O 37000FTHE LABOR COOE.FORTHE PERFORMANCE OF THE WORK FOR WHICHTHIS PERMIT IS ISSUED.MV WORKERS'COMPENSATION IN URANCF.CAR IER AN�POLI Ea aaE� CONStRUCTION Q ] CARRIER �_ PLAN REVIEW ZPOLICV NUMBER��� -' .•Cj� ELECTRIC Q 0 (fHISSECTIONNE�NOTBEO�NIPLEfEDOFT}+EPERMI�tSFOFiONEHUPDREODOI.LARS(5100�ORLE55). PLUMBING r � w I CERTIFYTHAT IN THE PERFORMANCE OF THE WOPK FOR WHICH TNIS PEAMIT IS ISSIJEO,I MECHANICAL �A:�� Z L)' SHALL NOT EMPLOV ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECTTO THE —.A...�.�� Uj WORKERS'COMPENSATIONLAWS ORNIA,ANOAGREETHATIFISHDUIDBECAM �NSPECTIONFEE = 3U&IECTTOTHEWORKERS'COMPE SATI IONSOFSECTION3'1000FTHE DE FO�T}1WITHCOMPLY TH OSEPR ION ISSUANCE y��q� � r p DAiE:��if r APPIICANT: SMIP �N4V 6< r� �u'id° W ENERGY P/C .e r�'+�T�!�A� WAFlNING FAILURE TO SECURE WOFI(ERS'COMPENSATION COVERAGE IS UNIAWFUL,AND SHALL BE !— LLSUBJECTANEMPLOVERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �����5 y DOLLARS(510D.o00�,IN ADDITION i0 THE COSTOF COMPENSRTION,�AMAGES AS PROVIDED FOR IN , �i �, .y � SECTION3loeOFTHELA80RCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: d CONSTFiUCTION LENDING AGENCY pRE-ALT FEE: O � I HEREBVAFFIRM UNDER PENALNOF PERJVRV THATTHERE IS ACONSTRUCTION LENDING AGENCV FOR THE PEF1fORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oB'�,CIV.C.). Z W � LENDEN'S MAME F— LENDEF'SADORE55 w ICERTIFYTHATIHAVEREAOTHISAPPUCATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES . � I AGREE TO CAMPLV W1TH PLL CITV AND COUNTV ORDINANCESAND STATE LAWS REIATING TO BUILOING � CONSTRUCT�ON,AN�HEFEBY AUTHORIZE PFESENTATIVES OF THIS COUNTV TO ENTER UPONTNE � ABOVE-MENTiONED FR07ER Y FOR INSPE wn vuarosEs. COMMENTS � l C,� � - m RMI E(PRI ,.. Q `. � � y SI REOFPERMITfEE D E = RECPL NO. _ _PAID BY __ ____VALIDATION__. ~ WHITE—Department Copy.YELLOW—Finence Copy,PINK—Assessor CoDY�GOLDENROD—File Copy,GREEN—ApplicanYs Copy ��.�y�ly� d�:�.'a;:, i :.ycn: i�, oS;f$?: '� :Yr';�:?+'-0 } �.,.a�+�- a�;�.i,���� ..14 ij;L", i' . .�. �• a°• � ..'� i r 7::-.:' � � . . � - � .� � �t� .� i . ^ , , ';0 � � ���� � �� � ' � . 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