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HomeMy WebLinkAbout16009 �L ( �t�t I,b { � i . CITY OF DIAMOND BAR � "•a - ----�� — DEPARTMENT OF COMMUNITY&DEVELOPMENT 5ERVICES � 21660 B.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 �� PRESS '�'^ � BUII.DING PERMIT APPLICATION _ .:. .,,,., x �,�R� o DDRESS.�a�3 C���L��G1� �'` DATECATION C �� NUMB R #/C c� ISSUE TYPE OCC APN LOT�— TRACT DATE_ �CONST. GROUP pOWNER ��4�_�I'/�f�/L`t-- o ADDRES C� C. �/ � ZONING SE78ACKS � CITY �ZIP_ TELri��� � Cs�"�S3'� FRONT RW ❑ APPLICANT TEL. REAR p � SIDE/SIDE STREET RW � � CONTRACTOR G� T�W R�G— �N�— SIDE ❑ oADDRESS w ��7 — PROPOSED USE �� TC� S � �� CITY LOSTW h"L L S p ZIP�.��_ TEL.S l Y�f) �2`'� '7k'� r...• e.✓O o 1'! � Gk'l 1 C�./ � ARCHlEISG/ �� �,JP��� T. � DESIGNER NO.DWEL. NO. NO. ADDAESS UNITS STORIES ��BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.P'T. FACTOR PSF ADJ.AREANALUATION y OOWNER-BUILDER DECLARATION ' SFR/ADDlREM � I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FFlOM 7HE CONTRACTORS LI- � Garage/Carport W CENSEUWFORTHEFOLLOWINGHEASON(SEC.7031.58USMESSANDPFOFESSIONSCOOE:ANYC�TVOq ZCOUMYWHICHREOUIRESAPERMRTOCONS7RUCI;PLTER,IMOROVE,DEMOUSH,ORHEPNRANVSTRUP (W patiO/DBCk W TUpE.PFYOH TO 17'S ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PEqMiT TO fllE A�SIGNED � � STATEMENT THAT NE OR SHE IS LICENSEO PURSUANT TO THE PROVSIONS OF THE CONTRACTORS L'I- ! CENSE UW(CHAPTER B(COMMENdNO WITH SECTION 7000)OF DIVISION 30F THE BUSINE9S ANO PRQ- u' POoUSpa 7� FESSqNSCOOE)ORTHATHEORSHEISEXEAAPTT4EREFROMANDTHEBASI3FORTHEALLEGEDEXEM7- V TqN.ANYVIOLATIONOFSECTIDN7051.68YANYAPPLICANTFORAPERMITSUBJECT57HEAPPLICAHfTO Z Re-Roof � �O� � A CML PENAIT/OF NOT MORE THAN FNE HUNDRE�OIXLAflS�1500).�: ' � � �I,ASOWNEROFTHEPROPERN,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPEF�SATION, � ComI1lBfClal " WILL DO THE WORK,AND THE STRUCTUfiE IS NOT INTENDEO OP OFFERED FOH SALE(SEC.7044,BU51- J � NE55 Ml�PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF � PRDPEFi�YVYFiO BU0.050R IMPROVES THEREON,ANO WHO DOES SUCH WORK HIMSELF OR HER5ELF ON Q THROUGHHISORHEqOWNEf4PLOYEES,PROVIDED7NAT5UCH�lAPROVEIAENTSARENOTINTENOEDOp CL� � OiFEREDFORSALEIF,HOWEVER,THEBUIl01NGORIMPROVEMENTI3SOlAWI7HINONEYEAROFCAMPLE- Z TqN,THE ONMERAU�LDER WILL HRYE 151E @URpEN OF PROVING THAT HE OR SNE�IO NOT BWLD OR = IMPf�VEFORTHEPURPOSEOF9AL�. W ❑1.11SONMEROFTHEPROPEpTY,AMEXCLt/ENELYCONTRACTINGWI7HLICENSWCqN7RAC70A5 � TO CONSTRUCT h1E PROJECT(SEC.7DA4,BUSINESS AND PROFESSIONS CODE:THE COMRACYORS LI- VdlUd�lOf1 ADJ.AREA W CENSEUWDOESNOTIIPPLYTOANOWNEROFAPflUPEPTYWHOBUILDSOR�MPROVESTHEREdN.ANb � WHOCONTMCT6FORSUCHPRQIECTSWIhIACONiRACTOR�S�LICENSEDPURSUNJTTOTHECONTMG QUANIITY DESCRIPTION FEE Y TORSUCENSELAWJ, � �IAMEXEMPTUNDERSEC. B.&P.C.FOPTHISREASON � � a LL" DATE OKNER �"" ,�, W � LICENSED CONTRACTORS DECLARATION W � t HEREBYAFFIRM 11NDER PENALTY OF PERIURY THAT I AM LICENSED UNQER PROVIS�ONS OF CHAPTER � � Y(COMMENCINO WITM SECTION 7000)OF DIVISION 3 OF TME BUSINESS ANp PROFESSIONS CODE,AND � X A/Y UCENSE IS IN ML FOiiCEAND EFFECT. m u� 2 / � UCENSE C SS G_ 7_�__LIC.NO. � L � � a ~ DATE � �__...�.._._ CONTRAC70R GI A��T��V� �- U W � WORKERS'COMPENSATION OECLARATION Q = U � I HEREBY AFFIRM UNOER PENALTY OF PERJURY ONE OF THE FOIIOWING DECLAHATIONS: � � 4 0 IMAYEIUVDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREWRWORKERS' _ � COMPENSATION,ASPROVI�EDk��SECTION3�n0UfTHELABORCAOE,FORTHEPERFORMANCE W .__ OF 1HE WORK FOR WHICH THIS PEflMIi IS ISSUED. � � XI W (�I HAVE ANO WILI_MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BYSECTION /�/e"/I /� /� O 37000FTHELABORCODE,FORTHEPERWRMANCEOFIHEWORKFORWHICHTHISPERMITIS ��1 X ISSUEO.MY NERS'COMPENSATIONWSURANCECARRIERANDPOLICYYUMBERARE: CONSTRUCTION 1 (�� � CARPoEP�e�t fgYI.L� x N� PLAN REVIEW � — � POLACY NUTABER_(G,�.� o��'G 7 ST�� ELECTRIC Q (IHLSSECIILWNFIDNO76ECXJMIP.EIIDOF�HEPEFiMRFSR�F10fdEWJ�DFEDUOLLARS(Et001�LE55a PLUMBING Z ICERTIFYTHATINT}iEPEPFOaIAANCEOFTHEWORKFOftWHICHTHISPERMITI5155UED,i I MECFIANICAL ('J SHALL NOT EMPLOYANV PERSON IN pNY MANNER SO AS TO BECOME SUBJECT 70 THE I � WORi(EiiS'CAMPENSATIONLAWSOfGALIFORNLqANDAGREETHATIFISFpULDBECOME I INSPECTIONFEE SU&IECTTOTHEWORKERS'C9MPENSATIONPROVIS�ONSOFSECTION37000FTHELABOR �gSUANCE � CODE,1 SH FOHTHWITH COMPLY WITNTHOSE PROVISIONS. /'� � � // /� �� p DATE: APPLICANT: S.�(.�_�_r�� 1"��� SMIP �[, IL W ENERGY P/C J WARNING:FAILURETOSECUREWOflKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE � SU&IEC7ANEMPLOYERTOCRIMINALPENALTIESANDCIVILFlNESUPTOONEHUNDREDTHOUSAN� ENERC�YPERMIT OOLLARS(5100 000).INADDITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SEGTION 37oe OF THE U180R CO�E,INTEREST,AND AT'fORNEY'S FEES. RETENTION FEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFIRM UNDER PENALN OF PERJURY THAT THERE IS A CONSTFUCTION LENDING AGENCY � FOR THE GERWRMANCE OF THE WORK FOR WHICH 7HIS PERAl1T IS ISSUED(SEC.30B7,CIV.C.). Z W � LENDER'S NAME _____ 1_-- LENDERSADDRESS _—. W I CER7IFY TNAT I HAVE REAO THIS APPLICATIONAND STATE THAT THEA90VE MfORMATION IS CORRECT. TOTAL FEES � � v �� � IAGREETOCAMPLVWITHALLCITYANDCOUNTVORDINANCESANDSTATElRWSRELATINGTOBUIL�ING � �� CONSTRUCTION,AN�HEREBV AUhIORIZE REPRESENTATIVES OF THIS CW NN TO ENTEq UPON THE 2 ABOYE-MENTIONEO PROVERTY FOR INSPECTION PVRPOSES. COMMENTS � �-A-y tnr� 7'� G���� m PERM� EE NAME(PflINn � v '1 � SI F PERNI E DAT = RECPT.NO. PAID BY VALIDATION ~ WHITE—Oepartment Copy,YELLOW—Finence Capy.PINY—Assassa Copy,CaOIAENR06--File Copy,GREEN—AppliranYs Copy .iA.,i,.-� :�..:n.: . ,.:..i, '. .. . ..�.�.` �"'«,•:�tl ' '-.. . . . x . � . . ' . 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