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HomeMy WebLinkAbout17353 (23) CITY OF DIAMOND BAR -----��`— �1EPAR1'NIENT OF COI�RMUNITY&c DEVELOPMENT SERVICES I � - 21825 E.Copiey Drive � (909)850-3I95 Fax(909)861-3117 PRESS '`'-.vw���� BUILDINGFERMITAPPLICA�'ION FIRMLY � JOBSITE � ���" C�C,�°U"���,� !�`,� APPLICATION PERMIT !C o ADDRESS_ `°� DATE �� � � NUMBERI E # � � APN LOT TRAC DA EE � � �� ONST. GROUP p OWNE������ � �` ADDRESS ZONING SETBACKS � CITY IP TEL. 1�� � F�EORT RW O ZAPPLICANT v�/�� �t!1'�— TEL. SIDE/SIDE STREET RW ❑ m CONTRACTO "" � ��'�S �L'J�'��" SIDE ❑ o C TMRE S � ZIP � .S TEL. n I� PROPOSED USE � �� �� �% w ARCH/ENG! z `DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES' � BEDROOMS �i � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� OWNER-BUILDEFi DECLARATION SFR/ADD/REM O . 0 I HEREBY AFFlRM UNOER PENALTY OF PERJURV THAT I AM EXEMPT FflOM THE CONTfiACTORS LJ- � Garage/Carport � W CENSELAWFORTHEFOLLOWMGHEASON(SEC.7037.SBUSINESSANDPFOFESSIONSCDDE:ANYCITYOR U COUNTVWHICHREDUIRESAPERMffTOCONSTRUCLALTER.IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W PdtiO(DOCk W TURE,PRIOR TO ITS ISS�ANCE,ALSD RE�l11RE5 THE APPLICANT FOR SUCH PERMIT'O FILE A SIGNED W � STATEMEM THAT HE OR SHE IS LICENSEO PURSUANT TO T-IE PROVISIONS OF THE CONTRACTORS EJ- ,� CENSE IAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINESS AND PR0- V' POOUSPe FESSIONSCODE�ORTHATHEORSHEISEXEMP7THEREFflOMANDTHEBA515FORTHEALLEOE7EXEMP- � TION.ANYVIOLATIONOFSECTION7o31.5BYANYAPPLICANiFOFiAPERMITSU&lEGTSTHEAPPLICANTTO z Re-Roof � �� �,�� AGVIL PENALTY OF NOT MORE THAN FIVE HUNDREO DOLLAFS(S5oD).): ��� ❑I;ASOWNEROPTHEPROPERTY,ORMYEMPLDYEESWITHYVAGESASTHEIRSOLECOMPENSpTION, � CofnmefCial � � Z , WILI W THE WORK,AND THE STRUCTLJRE IS NOT INTEN�ED Ofl OFFERED fOR SALE(SEC.7044,BUSI- J NESS AND PFiOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �" PROPEFNWHOBUILDSOFIMPPOVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m , CL. TFIFOUGHHISOflHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPRWEMENTSARENOTINiENDEDOR ' -,Q,� '�,OFFEPEDFORSA�E.IFHOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWfTHINONEYEAROFCOMPLE- , Z� TION,THE QNJNEfl-BUILDER WILL HAVE THE BUHPEN OF PFiDVWG THAT HE OR SHE�I�NOT BUIL�OR IMPROVE FO,R THE PURPOSE OF SALE). � W� ❑I,ASDWNEROFTHEPFiOPERTY,AMEXCLUa'IVELYCONTRACTINGWITHLICENSEDCONTRACTORS � . . '��, '70 CANSTRUCT THE PROJECT(SEC,7044,6lJSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81UfllI0I7 ADJ.AREA 'LLI'. CENSELAINDOESNOTAPPLVTOANOWNEROFAPRO?ERTYWHOBUlLDSORIMPROVESTHEREON,AN� � WHOCONTRACTSFORSI/CHPFOJECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE . Y TORS�ICENSE LAW.). � J � ,o� ❑IAM EXFMPT UNDERSEC. B.&P.C.FORTHIS REASON Q � � LL. � DATE OWNEq U � W o UCENSED CONTRACTORS DECLARATION W �� IHEREBYAFFIRMUNDERPENAL7YOFPERJURYTHAiIAMLICEN5E0UNpERPaOVI510NSOFCHAPTER � �(y 9�COMMENdNGWITHSECTION7o00)OFDIVISION30FTHEBUSWESSANDPROFESSIONSCO�E,AN� Z X MY LICENSE IS IN FULL FORCE AND EFFECT. 0 LICENSE LASS �?�� L1C.N0. ����� ` � d' f� �y J V� DATE /� �� CONTRACTOF�,.��-�Z��'�ca�6o�,,� � W � WORKEFS'QOMPENSATION DECLARATION � a � U � IHEREBYAFFIflMUNDERPENALTYOFpERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z � IHAVEANDWILLMAIN7AINACEHTIFlCATEOFCONSENTiOSELF-INSUREFORWORKERS' 2 ' CAMPENSATION,ASPROVIDEDBVSECTION370oOFTHELABORCODE,FORTHEPERFORMANCE U ¢ OFTHEWDRKFORWHICHTHIS',PERMITISISSUED. � - � �w , I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION MSURANCE,AS RE�UIRED BY SECTION �/��u, E��' � Q 37ooOFTHELABORCO�E,FOR',TH�PERFORMANCE�FTHEWOFKFOFWHICHTHISPERMITIS ��y 6 o p� ISSUED.MYWORKERS'COMPEMSATIONWSURANCECApRR�IER N,�DdPOLICYNUMBERARE: CONSTRUCTION �s .s .j CAflRIEfl��i�p��F'��'7T�l���%�/�� PLANREVIEW _�� POLICYNUMBER ELECTRIC � ' � (IFIISSECiIONNEmNOTBE PLEfEDOFiH:PERM(TISWflQ4EHUVDI'EDDDI.IARS�$100JORLESS). PLUMBMG �Z I CLflTIFYTHAT IN THE PERFORMANCE OPTHE WOFK FOF WNIGFi THl ERMIT IS ISSUED,i MECHANICAL ('3 SHALL NOT EMPLOY ANY PERSdN IN ANY MANNER SO TO B OM UBJECi TOTHE .� X'ORKERS'COMP=NSATIONLA�PlSOFCALIFORNIA,A AGRE H FISHOULOBECOME INSPECTIONFEE � �SUBJECTTOTHEWORKERS'COMPENSATIONPROV IDNS S �IDN37000FTHELABDR . � +� CODE,I SHALL FORTHWITH COMPLV WITH TH ' ROVI NS ^�� ISSUANCE �� ,,,,9� � �� SMIP � l4d'�✓ p DATE: APPLIGANT: J ENERGY P/C J WARNING�FAIWRETOSECUREWORKERS'COM NSATIONCOVERAGEISUNLAWFUL.ANDSHALLBE �y SUBJECTANEMPLOYER70CRIMINALP,ENALTIESANDCIVILFINESLIPTOONEH�NDREDTHOUSAND ENERGYPERMIT DOLL4FlS(S1 oo.oaoj,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37080FTHELABOFCOOE,IN7E:�EST,ANOATTORNEY'SFEES. RETENTIONFEE: �p CONSTRUCTION LENDING AGENCY PRE-ALT PEE: O 4 I HEREBY AFFIRM UNDER PENALTY OF PERJUflY THAT THEFE IS A CONSTRUCTION LEhDING AGENCY FOft THE PERFORMANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSVED(SEC.309],CN.G�. Z W ? LENOER'S NAME � � LENOEF'SADDRESS f� '^�, � ICERTIFYTMATIHAVEREADTHISAPPLIGATIONANOSTATETHATTHEABOVEINFOflMAiIONISCOflRECL TOTAL FEES �r 1 V W IAGREETOCOMPLYWITHALLGITYANDCOUNTYOR�INArKESAN�STATELAWSRELATINGTOBUILDING - d �. CONSTRl1CTION,ANOHEREBYAUTHORiZEREPRESENTATIVE50FTHI5COUNTYTOENTEHUPONiHE � ABOVE-MENTIO ED PROPERTY FOR INS ECTION PURPOSES. COMMENTS - � �"W 6�. _'_—_ m PERMITT IUE(P NT) � , �-��� , � SIGN URE PEflM1TT � DATE � Y RECPT.NO. 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