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HomeMy WebLinkAbout16131 CITY OF DIAMOND BAR /� �--�'�— DEPAR'TMENT OF COIvYMLJNITY&DEVBLOPMENT SERVICES , " � � 21660 E.Copley Drive Suite 19� ..,1 (909)860-3195 F�(909)861-3117 PRES$ � eN° BUQ.DING PERMIT APPLICATION FIRMI.Y JOBSITE -7_g ° A " APPLICATION /�- PERMIT / P/C �' ADDRESS o�L ��/.�3 �D�� -4.�-�°�� �A.+ ` DATE � � Ilf���NUMBER 1...� � # �: ISSUE TYPE OCC �- APN LOT�__� TRACT �` DATE CONST. GROUP p' OWNER �/YI �-T+���..+ti�_r�; ADDRESS .�' ZONING SEBACKS z� CITY ZIP TEL. FRONT RW ❑ , APPLICANT TEL. REAR ❑ g; SIDEISIDE STREET RW ❑ �� CONTRACTOR� _�.� � _���.�.-._ SiDE ❑ � ADDRES ��h.�s.t.� ��aY'� �' CIN ZiP� TEL.y�� _, PROPOSED USE � o;. ARC� . � � � DESIGRER _ NO.DWEL, NQ.s. ` . , ,NO, � ; ADDRESS � I ; UNITS � STORIES � BEDROOMS �= CITY C.R�-.� ZIP 7EL .� ..3 � ,�; y,. f DESCRIPTION SQ.FY. FACTOR PSF ADJ.AREANALUATION - ;p�E. ' OWNER-BUILDER DECLARATION SFR/ADDfREM O< -:p' ' 1 HER�Y AFFlRM UNDEfl PENALTY OF PERJUHY THAT 1 AM EXEMP7 FROM THE CONTRACTORS LI� �, GHfBgB/CflfPOft .W.. CEN8ELAWFORTHEFdlOWINGRFA50N�SEC.7o3t.58U5�NESSANDPROPESSIONSCODE:ANVCITYOR ;(n: -'U� 'COUNiVWHICHpEWIRE3APERMITTOWNSTRUCT,AITER,IMPROVE,�EMOLISH,ORREPAIRANYSTRUG ;((J pdI10/DBCk ��i TUflE,PRIOFi TO ITS ISSUANCE,AlSO REW IRES THE APPLICANT fOR SUCH PERMIT TO FILE A SIGNED �' STATEMENi THA7 ME OR SHE IS LICENSED PURSUANT 70 THE PROYISION3 OF THE CANTPAC70R3 U� 'e W -�- CENSE UW(CHAPTER 9(COMMENCMG WITH SECTION 7000)OFDIYISION 3 OF THE BU61NE&6 AND PRO `� POOUSpB . �. FESSIONSCODE�OATHATHEORSHEISEXEMPTiHEAEFROUANDTHE6ASISFORTNEALLEGfiOEXEMP� i TqN.ANYVIOLqTIONOFSECTION7031.5BYANVAP7LICANTFORAPERMtTSUSIEGTSTMEAPPL�CANTTO .�Z R8^ROOf L.y�,rsf o � -�„�, ACMLPENALNOFNO7MOflE7HANfiVEHUNDREDDOLLARS(SSoo)J: OI,ASOWNEflOFTHEPflOPERTY,ORMYEMPIOYEESWITHWA6E3ASTHEIPSO�ECOMPENSATION, �G, COi11fi18(CIHI ' �.: WIll00 THE WOfUC,AND THE STRUCTURL IS NOT WTEN�ED Ofl OFFERED FOR SALE(SEC.7044,BUSI- :�J -' NESS/WD PpOFES5ION5 CODE:TNE CONTflRCTORS LICENSE LAW DOES NOTAPPLY TO!W OWNER OF �f PROVER7YWHOBUILDSORIMVROVE5TNEflEON,ANDYMO�OESSUCHWOflKNIMSELFORHEfl9ELFOR '_ �--�: iHflOUGHHI50RMEPOIVNEMPLOYEES,PROVIDEPTMATSUCHIMPROYEMENTSARENOTINTENDE00R �m � W:` OfFEREOPoflSM.EIFNOWEVER7HEBUILO1N60flIMPROYEMENT�SSOLDWffHINONEYEAROFCOMPLE- �', TION.THE ONRlER-BUIIDER WILL W WE THE BURDEN OF PqoVING THAT HE oq SHE OID NOT BUILD Op - �: DAPROVEFORTHEPUR70SEOFSALE�. ' ❑I.ASONR7EflOFTHEPROPERTY.AMEXCIUSIVEIYCONTRACTIN�WIh!LICENSEDCONTFiACTOR3 ' �� TO CANSTRUCTIHE PflOJECT i5EC.7014,6U31NESS AN�PROFESSION9 CODE:THE CONTRACTORS LI� Vd�Ud110(1 _._ _�_...__._aD�.NflEA_,___ _„_.,_ ____._ LL!� CENSELAWDOESNOTAPPLV70AN0\5T'EROFAPROPERNWFIOBUILDSORIMPROVESTHEREON,AND :� NhiOCONTRACTSFOPSUCHPpQ1ECTSWITNACONTHACTORiS)LICEN5EDPURSUAMTTqTHECONTR4P Qy�pNTI7Y DESCRIPTION FEE .�_- TORS LIGENSEtAW.). �' ❑1 AM EXEk�P'P UNRER SEC. B.&P.C.FOR THIS REASON � J ' O. EF U 3 � �� DAYE ONMER�. �" � Z V ttl o¢ LICENSED CONTRACTORS DEGLARATIQN � 2' INEREBYAFFIRMUNOERPENAI.TYOFPERJURYTHF71AMLiCENSEDUNDERPFOVISIONSOFCHAPTER , � �� e(COMMENCIN(i W17H SECTION 7000)OF�IYISION�OF Tri[BUSINESSANO PROfESSIONS roDE.AND - z AM IICENS6 IS IN FULI FOFCE AND EFGECT. � LLl �}at ,y � LICENSE CLA55_��+-�-�—�—LiC.No. -�y,�.6'caC.w[s 8 . :. � � �- J pATE�=��f�� CONTRACTOR��• d w �-�� �- �WOFlKERS'COMPENSATION DECLARATI6N :� ¢ � U � IHEREbYAFFIRMUNDERPENALTYOFPEAJUHYONEOFTHEW:IOWINGO[CI.HRATIONS: � � Z Q � ,IHAVEANDWILLMAINTAMACERTIFICATEOFCONSENTTOSLLFINSURE�OflWORKERS' ' Z CqMPENSATION,AS PflOViDF.O BY SECTION 9)OOOF THE 1A90R CODE,FOR THE PERF-0RMANCE W OF THE WORK FOR WHICH THiS PENMIT IS�SSUED. � Q Q �1 iiAVE:AND WILL��NTWN WORKERS'COMPENSATION INSUFiANCE.AS REQUIRE�BY SECTION � 370nOFTH6L?13OF7CODE,FQRTHEGERf-0RMANCEOFiHEWORKFORWHiCHTHiSPEHMiT15 ����1 �(� _.. ISSUED.MY WORKEAS'^�GENSATION INSURANCE CANl11ER AIvO POLICY. biBERARE: � CONSTRUCTION v y CARRIER,__ � a '� ��'� � PtAN REVIEW zPOLiCYNUMBER�_��J�-� �� ���=' ELECTRIC �L __— __. __ ...__— . o �rwssEcno+vr�[�raoreecr.t�,t�ErIDOFrt�aEtn�atsr-0qon�va;roawDourRs(flao�oniEss? PWMBING w Z 1 CEfl71FY TNAT MITME PERFOPMANCE OF THE WORK FOfl WHICH THIS PERMIT IS ISSUEO,I MECHANICAL � SHAtINOTEMPLOYANYPER50NINANYMANNERSOA5708ECOMESU6JECTTOTSiE � WORKERS'�:b�RPENSqT�ON IAINS Of CALi.^ORNIl�AND AGi7EE THAT If I SHOIII.[]BECOME INSPECTION FEE - � SU&IF.C7TOTNEWORKFRS'cxiMPeNSATiO�PHOVISIONSOFSECTION37000FTHELABOR t" CODF.,I SHALL EORiHW�TH COMPLY WlTH THOSE PflOVISION3. ISSUANCE � y ry p DAIE:'��+J'¢/ APPLICANT. v t � �i�R�l,r.�+'_ SMIP ,.. 6 J / ENERGY PIC WARNMG:FAILUR TO SECURE WORKENS'COMPENSATICN COVERAGE ISUNtAWFUI,hND SHALL BE �� SL1&)ECTANEMPLOYEFITOCRIMINALPENALTIESAN�qVILfINESUPTOONENUN�REDTHOUSAN� ENERGYPERMIT � _ OOUARS(i100.000j,W ADDITION TO THE COST OF cY1MPF.NSATtoN.DAMAGES AS PROYIDEP FOR IN - — ¢ SECTbN31080FTHELA90RC0[)E,INTERE57,ANDATTORNEY'SFEES. flETENTIONFEE: W CONSTRUCTION LENDIN6 AGENCY PRE-AL7 FEE: � - O � IHEFEeYAFFIRMUNDERPENALiYOFPEftJURYTHATTHEflEISACONSTPUCTION�[NDINGpGENCY , _ PoFl THE PEAFOqMANCE OFTHE WORK FOR WHICHTHIS PEHMIT IS ISSUED(SEC.9oW,CIV.C.j. Z W � LEN�ER'S NAME _ � LENOER'SADDRESS r WICERIIFYLHATIHAVEREA�THISAPPLICA7IIXJANDSTATETHATTHEABOVEINFOftMATIONISCORHECT. TOTALFECS - ��y� � IAGREETOCOMP4YWITHALLCINANDCOUNNOR�INANCESANOSTATELAWSflELATINGTOBUIL�ING CANSTRUCTION,AND HEREeY AUTHOflIZE REPRESENTATIVES OF 7HI5 COUNTY TO ENTEfl UPON THE Z AeOVE-MENTIONED PAOPERTY GOR INSPECTION FUPPOSES. 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