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HomeMy WebLinkAbout15110 (20)rr, [�II.�I) It11l.i PERMIT APPLICATION CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Ddve Suite 190 (909) 860-x.193 Fax (909) 861-3117 BUILDING DATE ILA NUMBER ! A TE tJ DATE CONST. GROUP SS ADDRJOBSESS... FRONT RW ❑ REAR p 3 SIDE p PROPOSED USE 111 4 APN LOT TRACT UNITS STORIES BEDROOMS OWNER IfeSLt1C"' CSiZtT JS7ta1rJ DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION ADDRESS -s SFRIADDIREM � Garage/Carport CITY '� ZIP TEL. MA""aj7► APPLICANT TEL. PalklDeCk CONTRACTOR Pool/Spa ADDRESS 9 E -Rod $`,�� Commercial CITY ZIP TEL..S""ESC7C� ARCWENG/ DESIGNER t ADDRESS Valuation ADJ.AREA CITY ZIP TEL. g C OWNER -BUILDER DECLARATION ^� I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI. CENSE LAW FORTHE FOLLOWING REASON ISEC.7031.6"NESS AND PROFESSIONS CODE: ANYCRYOR ,1(CjJJ COUNTY WHICH REOUIRESAPERMIf TO CONSTRUCT,ALTER. IMPROVE. DEMOUSH,OR REPAIR ANY STRUC- TURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED STATEMENT THAT HE OR -6 IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS Ut \r CENSE LAW (CHAPTER I (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS OWE) OR THATHE OR SHE 18 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF GEOT40N 7031.6 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO ACIVR PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS O L AS OWNER OF THE PIOPERTY.011 MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE- THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY' WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR C THRCUCM HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR Ems+ OFFERED FOR SALE iF.HOWEVER THE BURDNGOR IMPROVEMENT ISSOLDWITHINONEYEAR OFOOMPLE- I" THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR CONSTRUCTION IMPROVE FOR THE PURPOSE OF SALE} C Q l AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH UMSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC, 7044, BUSINESS AND PROFESSIONS GCOE: THE CONTRACTORS U - U C CENSE LAW DOES NOTAPPLYTOANOWNER OF A PROPERTYWHO SUEDS OR IMPROVES THEREON. AND WHOCONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORJS)LICENSED PURSUANTTOTHECONTRAC- PLUMBING l b TORS LCGENSE LAW.). MECHANICAL ��� O I AM EXEMPT UNDER AEC. B. i P.C. FOR THIS REASON INSPECTION FEE DATE OWNER ANCE a SMIP`� LICENSED CONTRACTORS DECLARATION p_[ i I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED VNDER PROVISIONS OF CHAPTER (COMMENCING WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND RETENTION AO I ILD J MY LICENSE 18 N FULJ�FOORRCCE AND EFFECT. PRE -ALT FEE: �j �'w A C JCA -# LICENSE CLASS y r '� UC. NO. - � DATE 47J"{S'�CY� CONTRACTOR WORKERS' COMPENSATION DECLARATION COMMENTS A I HEREBY AFFIRM I44MR PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' __i COMPENSATION, AS PROVIDED BYSECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHOCH THIS PERMIT IS ISSUED. —, HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIRED BY SECTION g 37000FTfE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ISSUED. MY WORKERS�''�O`OOMPEN��S��ATION NSLI_R1ANNCE BRIER AANOO POLICYNUMBER AAE: _sg3t T\©(acre CARRIER �-I:i`gg*_ +..7rJ� �y� POLICY NUMBER EC!- zn— \ (11 swnONNEEDNOTBECOMPLETEDOF7HE PERMIT IS FOR ME HLNDREDOOLLMtl(6100)OR LESS) r I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITS ISSUED. 1 SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE W3 WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME KERS' COMPENSTH N 3700 OF THE LABOR CODE. I SHALL FORTH C��OP►OE.IU�S/�H^A��L,L//F.�U�rR'T''�HWRTi COMPLY WITH SE PROVISKONB. ^� DATE: �Tr,� APPLICANT: WARNING: FAILURE TO SECURE WORKERS' OOMPENSATIO4 COVERAGE 13 UNLAWFUL., AND SHALL BE y„ SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS IMOD, 000). IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR OWE. INTEREST. AND ATTORNEY'S FEES. W� q. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THATTHERE IS ACONSTRUCTION LENDING AGENCY 4. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I3 ISSUED (SEC. SM. CIV. C.I. Z^ W LENDER'S NAME UENDERSADDRESS Illggg��� �ULI 1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THEASOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. PERM N SIGNATURE OF PERMITTEE DATE 4) PRESS FIRMLY APPLICATIO PERMIT / P/C DATE ILA NUMBER ! A ISSUE � t TYPE OCC tJ DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR p SIDEISIDE STREET RW Q SIDE p PROPOSED USE 111 4 NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFRIADDIREM Garage/Carport UJ PalklDeCk U- Pool/Spa ZRe -Rod q Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE W�I J W, Z. CC \r _U Z 4S S W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING l b MECHANICAL ��� INSPECTION FEE ANCE a SMIP`� ENERGY PIC P t T� ENERGY PEFG 1 RETENTION AO I ILD J PRE -ALT FEE: TOTAL FEES COMMENTS RECPT NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW--Finenoa Copy, PINK—Assessor Copy, GOLDENROD --File Coj* GREEN--Applicent'3 Copy