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HomeMy WebLinkAbout16025 (20) � _!� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVLLOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)560-3195 Fax(909)861-3117 PRES$ q�... BUILDING PERMIT APPY.ICATION. ._.`. .,- ... �..... w . . .,.. R��RM�.Y � JOBSITE • }� APPLICATION PERMIT �P/C o ADDRESS I� '" T � d DATE � � �� NUMBER � #1 c�+ ISSUE !� TYPE OCC APN LOT TRACT DATE V CONST. GROUP p OWNER �,�[�`"7 o ADDRESS ZONING SETBACKS Z CITY ZIP TEL. REO�NT RW Q g APPLICANT � TEL. SIDE/SIDE STREET RW ❑ � CONTRACTO /� ��/l� SIDE p � ADDRESS ` ����'T��G PROPOSED USE � �'"" � � CITY.�,_�y�'�_ ZIP TEL. Pu ARCH/ENG/ � J(� � DESIGNER NO.DWEL. NO. N . � '�" ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.ARErWALUATION OOWNEfi-BUILDER DECLARATION SFR/ADD/REM ._ p 1 MEREBY AFRRM UNDER PENALTY OF PEFWRY THAi I M1 EXEMPT fpOM THE CONTRACTORS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWINGREASON�SF.C,7031.SBUSINESSANDPROFESSIONSCODE:ANVC�NOR C.] COUNTYWMCHRECfUIRESAPERMITTOCONSTRUCT,ALTEP,P.IPROVE,OEMOLiSH,ORflEPAiRANYSTRIJG W pa�io/Deck WTURE,PFIOR TO ITS ISSUANGE,AL50 REQUIRES THE APPLICANT FOP SUCH PEflMR TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE GROVISIONS OF 7HE CON'RACTORS L4 � GENSE LAW(CHAPTER V(COMMENCINd WI7H SECTION�000)OF�NISION 3 OF iHE BUSINE55 AND PRO- u' POOUSPd FESSIONSCODE)OfiTHATHEORSHEISE%EMPiTHEFlEFROMANDTHEBASISFORTHEALIEGEDEXEMP- � TION,ANYVqLATIONOFSECTION7031.68YANYAPPLICANTFORAPEFMITSU&IECTSTHEAPPLICANTTO z Re�Roof � ACINL PENALTY OF NOT MORE THAN fIVE HUNDRED DOLlAflS�5500).): � ❑I,ASOWNEROFTHEFROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPF.NSATION, � COrtl�lfefGial - WILL 00 THE WORK.ANO THE STRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7oa,BU51� J NESS AND PROFESSIONS OODE:THE CANTRACTOiiS LICENSE L4W OOES NOT APPLY TO AN OWNER OF � VROPEfiTYWFi08UttD50RIMPROVESTMEREON.ANDWHOD0ES5UCHWORKHIMSEIFORHERSELFOR m � THROUGH HIS OR HER OWN EMPLOYEES.PFOVIOE�1NAT SUCH IMPROVEMENTSARE NOi INTENDED OR W OFFEREDFORSALEIF,HOWEVERTHEBL��L�INGORIMPNOVEMENTISSOIDWITHINONEYE0.ROFCOMPIE- 0 �TION,THE OWNER-6U�LDER WILL HAVE TNE BURDEN OF PflOViNO TiAT HE OR SHE DID NOT BUIfD OR z IMPROVEFOR7HEWRPOSEOFSALE}. w ❑I.ASOWNEpOF7HEPROPEHTV.AMEXCLU5IVLLYUJNTRACTlNGWITHLICENSEDCANTRACTOR3 �� � TO CONSTRUCT TFiE PROJECt(SEC.70It,BUSINESS AND PFlOFESSIONS C6DE:THE CONTRACTORS U- VfllllafiOtt ADJ.AREA W CENSELAWDOESNOTMPLVTOFWOWNEROFAPROPERNNRiO8U14D50R11APROYE5TFIEREON,AND � WIiOCONTMCTSFORSUCHPROJEC7SWITHRCONtRACTOR�S7LICEN&EDPURSUANTTO1FiECONTqAG QUANTITY DESCRIPTION FEE Y TORS LICENSE IAW.). —. � ❑I AM EXEMM UNDER SEC. B.8 V.G FOR7H15 REASON U � � LL �ATE OWNER_,_ � z W Y LICENSED CONTRACTORS DECLARATION �j � -- 1 NEREBY AiFIFM IIN�ER PENAlIY OF PERJURY iHAT I AM UCENSED UNDEP PROVISIONS OF CHAPTEfi �r {� i(COMMENCINO W17H SEC7pN 700oJ OF 01VISION 3 0F THE BUSINE&S AND PROFESSIONS CODE,AN� � �_ X MY UCENSE IS IN FULL F-0RCE AND EFFECT. m � UCENSE CLASS�/��LIC.NO.__�J��._� � V UATE_�/ /�._ GONTRAGTOR _j�(� a W �� � WORKERS'COMPENSATION DECLARATION Q � I HEREBY AFFIRM UNOF.R PENALTV OF PERJUfh'ONE OF THE FOLLAWING DECLARATIONS: U � z Q 0 _INAVEANOW�LLMAINTAINACERTIFICATEOFCONSGNTTOSELF�INSUREFORWORKERS' 2 � I;CM/PENSAYION,ASGROVI�ED6Y5ECTION37ooOFTHEL4BORCODE,FORTHEPERFORMANCE IU OF TNE WOflK:OR WNICH TMS PERMIT IS�SSUED. � � � __I HAVE M!U WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS FEQUIREO BY SECTION 44���+fj ,/� � `t Q3700 OF THE LABOR CO�E,FOR THF PERWRMANCE OF THE WORK FOft WHICH THIS PEFMIT IS i �(�V '! /J �1 ISSUED.MY WORKERS'COMPENSATKKJ INSURANCE CARPIER AND POLICY NUMBERAAE: CONSTRUCTION __ �L //� y cAaRi6R�--�;��-- ` �'`� '__�'Z__— PLAN REVIEW Z POLICY NUMBEA�_'�- �._���_ ELECTRIC _ � Q 0 (IHISSECipNNE�NOi8E00MPLETEDOFTI'�EPEPoM't5FOR01JEVIUt.0�1EDCtOLLFAS(51Co)OFLESSF PLUMBING ! Z I CERTIFVTHAT IN THE PERFORMANCE OF THE WOHK FOR WNICH THIS 7ERMIT IS�SSUEO,1 MECHANIGAL (�T SHALLNOT EMPLOYANV PEflSON IN ANY MANPlER SO AS TO BECOME SUBJECT TO THE , � WORNERS'COhIPENSATIONUW80FCALIFORNIA,AN�AGPEE'TNATIFISHOULD6ECOME INSPECTIONFEE __ � Sll&IECT TO THE VJOFdNERS'COMPENSATION PROVISIONS OF SECTION 37DD OF TME L1+B09 CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE '�� a � Gj DATE: D APPLtCANT: _, �,� SMIP w — � �—.� —, WARNINO:FAILURETOSECURE WORKEflS'COMPENSATiON COVERAGE�S UNLAWFVL,AND SHALLBE ENERGV P/C J SUBJECTANEMPLOVERTOCFIMINALPENALiIESANOCIVILFMESUPTOONEHUNDREOTHOUSqN� LL DOLLARS(5700,OW�.INADOITIONTOTHEC0.S70FCOMPENSATION,DAMAGESASPROVIDEDfORM ENERGV PERMIT J SECTION 9708 OFTHE LABOR CODE,INTEAEST,ANO ATTOqNEV'S FEES. flETENTION FEE: 2 ' � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _.___ � IHEPEBVAFFIRMUNDERPENAITVOFPERJURVTHAiTHEPEISACONSTRUCTiONIENDINGAGENCY FOR TME PERPoRMANCE DFTHE WORKFOR WHICNTHIS PERM1TiS IS5UE�(SEC.3oe'l,CIV C.�. Z W � LENDEP'SNAME_ _ ' �� � F- LEN�ER'SADDRESS �� �` y, � TOTALFEES V W I CERTIFY THAT I HAVE READ THIS APPLICHTION ANO STATETHATTHE AHOVE INFORMATpN IS CARREGT. � IAOREETOCAMPLYWIiHAllCI7VANDCOUNTYOROMANCESANDSTATEL4WSPElATiNGTOBUIL�ING . CONSTRUCTION,AND HEREBY AUTHORQE ftEPflESENTATNES OF 7Vi15 COUM1TV TO ENTER UPON THE � � ABOYE-MENTIONEDPROPERTYFORINSPECTIONPURPOS[5. COMMENTS y � � o [�� ) � •..:J- � .. � . � , m PERMITT E(P INT) I j� � . .�� ¢ I I V �_ .. . , ..: .. . .. � _ y SIGNA O E �ATE .,. . = RECPT.NO. ' PAID BY VALIDA7I�N ~ WHITE--Department Copy.YELLOW�inance Copy,PINK—Assessor Copy,GOLDENR06—Fiie Copy,GREEN—Applicant's Copy .�., ...,,...'. .:-""-' .. ' � ." '.. . :J,�' . . .� ..: - ' . _ �� 8 � � � �� � � , . � � � , � � � . � � � � � �,. 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