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HomeMy WebLinkAbout10761 I CTI'Y OF DIAMOND BAR COMMUNTI'Y DEVELOPMENT DEPARTME I _ 21660 E.Copley�rive Suite 190 PRESS (909)8643195 Fax(909)8613117 �'"N' BUILDING PERMIT APPLICATION FIRMLY o DDRIESS I � F � �C�"'�'�``�d��^ DATEICATION "� � NUMBER� #`C ��� c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �.� p ry p ADDRESS �Sd�1+'� - ZONING SETBACKS EX P�i-t��.J Z CIN _ ZIP TEL. FRONT AW ❑ o APPLICANT f'1�9�' ,,�d4�f��»*�TEL. "s e'c�� �°-i REAR ❑ � SIDFJSIDE STRA�T_��� RW ❑ � CONTRACTOR ����'��A l�C��'��' �� � SIDE ❑ ADDRESS .r-�-��� �/�- PROPOSED USE � CITY ZIP TEL. o ARCHlENG/ W DESICaNEfl NO.DWEL NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. �:. � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � p� OWNEft•BI;ILDER DECLARATION SFR/ADD/REM O p. I HENEBV AFFIRM UNDER PENALN OF 7ERdURY 7HAT 1 AM EXEMPT FROM THE CONTfiACTOPS LI• GHf898/CBfpOR W CENSEUWFORTHEFOLIOWMGREASON(6EC.7031.58USINESSANDPROFESSIONSCODE:ANYGTYOR � (n U� COUNTYWHICHREWIRESAPERMITTOCDNSTflUGi,RLTER,IMPROVE,DEMOLISH,ORHEPAIRPNYSTRUC- � W patiolDedc WTURE,CRIOR TO I7S ISSUANCE,ALSO REOUIRES THE APPLICANT FOH SUCH PERMITTO fILE A SIGNEO W - � S7A7EMENT THAY HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CANTRACTORS LL .,� CENSE LAW(CHAPTEP e(COMMgiCIN6 W�iN SECTION 7000J OFDINSION 3 DF THE BUSINESS AND Pfl0- LL PooUSpa � FESSIONSCA�E)ORTHATNEORSHEISEXEMPTTHEREFHOMANOTHEBASISFOR7MEALLEOEDEXEMP- � _.�� V TION.ANVVIOLkTIDNOFSECTION7031.60VANYAPPUCANiFORAPEHMITSU&IECTSTHEAPPlIC/WTTO B�R001 -s dG���r -'r�%���"a 4.t� � ACIViI CENALTV OF t�T MORETHAN FIVE HUNDRED DOLtARS(5500).): 0 ❑I.ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIHSOIECOMPEN3ATION, � �mmercial Z WILL DO THE WORK,AND 7HE STRUC7URE IS NOT INTENDED OR OFFERED fOR SALE(SEC.7aa,BUSI- J NE55 AND PROPESSIONS COOE:THE CANTRACTORS UCENSE LAW DOES NOT APPLY TO AN OVfNER OF N PPOPERTYYNiOBUItASORIMPROVESTHEREON.ANDWHODpE55UCNWORKNIMSELFdRHERSELFOR � C[ THROUGHNISORHEROWNEAIPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTMTENOEDOR m � OPFEREDFOReALEIFHOWEVER,THEBULDIN�ORIMPROVEMENTISSOIDWITHINONEYEAAOFCOMPLE- _ . Z TIOtJ,THE OWNER-8t111DER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE�ID NOT BUIL�OR � IMPROVE FORTNE DURPOSE OF SPLE}. Vy ❑I,ASOWNEflOFTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTOR6 � TO CANSTRUGT TME PROJECT(SEC.7049,BUSINE55 AND PROFESSIONS CODE:THE CONTFiACTOqSII- V81U8f10(1 ADJ.AREA W� CENSELAWDOESNO7AVPLY70ANOWNEROFAPROPERTYWHOBUILDSORIAIPFiOVESTHEREON,AND F WHOCONiMCTSFOHSUCHPROJECTSWITHACONTRACTOR(S)UCENSEOPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TOHS UGENSE IAW.). 0 ��AM El(EMPT UNDEH SEC. B.8 D.C.FOR THIS FiEASON � � � ��}� � � LL" DATE OWNER F Z W � � LICENSED CONTRACTORS DECLARATION W .� F a � ��`�p� � 1 HEREBYAFfIRM 11NDER PENALTY OF PERJURY 7HAT IAM LICENSEO UNDER PflOVIS10N&OF CHAPTER � p� 9(COMMENCIN6 WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AN�PFOFESSIDNS COOE,AND z W MY UCENSE IS IN FULL FORCE AN�EfFECL � m s�".Jf�y� ,e''rs�� o �.-�� ����`g'� � 9�9 �r LICENSE CIASS LI0.NO. �g J VDATE �"�~� � CONTRACTOR �s�y . � O. . �y g' W I �a�✓7Y�g"?��" S � WORKERS'COMPENSATION DECLAAATION ���^�j 1 � ¢ � = U � IHEREBYAFFIRMUNDERPENALNOFPERJURYINJEOFmEPoLLOWINGDECLARATKKJ9: u, z -�-�'�G� �. ':4,�' � C] I HAVEAND WILL MAINTAIN ACERTIFICATE OF C�ISENT TO SELF-INSURE FOR WORKER6' _ , Q COMPENSATIOH.ASPRDVIDEDBV3ECTION91000FTHElABOqCOUE,FORTHEPERFORMANCE U OF iHE WORH FOR WHICH THIS PERMIT 161SSUW. W p � _ W 1 HAVE AND WILL MAINTAM WORKEHS'CAMPENSATION INSURANCE.AS RE-0UIREO BV SECTION ,r� .. Q 37000FTHELABORGODE.FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMiTi � � ISSUED.MYWORKERS'Q�MPENSAT INSUfiANCECARRIERAN�POLICYNUM�E/RARE� CONSTRUCTION j CAfiRIER -r""�������� _'"+� � PLAN REVIEW - l p-' � Z poucv NUMeEa "� - -- -- � ELECTRIC � ¢ 0 (f}ASSECIICNNE�N�TBEOOMPLEfFDOF7HEPERMfISFORCNEHIJPDfiEDDOL1AflS(SiW)ORLESS�. PLUMBING Z I CEH7IFV 7HAT IN THE PERFOHMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUEO,i MECHANICAL (�j SNALLNOTEMPLOVANYPEti50NINANVMANNEfiSOASTOBECAMESU&IECT70THE � N WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE - S�fl1ECT TO THE WORNERS'CAMPENSATION PqOYI510N50F SECTION 37 OF 7N tABOR � CODE,I SHALL FORTHN7TH COIAPLY WITH T/HO�SE PROVI�N S.�� ISSUANCE � ('/� � DATE:�'�--_.�� C"" L.'�E"_ `"``�' SMIP E � -.� � APPLICANT. '" +r���" � ENERGY P/C � WARNING:fAIW RE TO SECURE WORKERS'COMPENSATIDN CAVEfiAOE IS UNIAWFU�,AND SHALL BE LL SU&1ECTANEMPLOYEflTOCRIMINALPENALTIESANDCIVILFMESUPTOONEHUNDRE�7HOUSAND ENERGYPERMIT DOLLARS�Si00.OW1.INFODITIONTOTMECOSTOFGOMPEN5A710N,DAMAGE5A3PROViDEDFORIN - — — - ----------------� � SECilON3l080FTHEU190RCODE,INTEREST,ANDATTORNEV'SFEES. - RETENTIONFEE: � d CONSTRUCTION LENDING AGENCY pRE-ALT FEE: qY'� � .IHEREBYAFFIqMt1NDERPENALTVOFPERIURYTHATTHEflEISACONSTRUCTIONLENDINOAOENCV �"�% =��' •R•�6 __ __ FORTHE PERFOPMANCE Of 7HE WORK WR WHICH THIS PERMIT IS ISSUED(SEC.3091,CN.C.). Z W � IEN�ER'S NAME F— IEN�Ei73ADDRESS _ WICERTIFYTHATIHAVENEAD7HISAPPLICATIONANDSTATETHA7THEABOVEINFORMATIONISCORRECL TOTAL FEES � � � I AGREE TO COMPLY WITH ALl CITV AND CAUNTY OfiDINANCES AN�STATE LAWS RELATING TO BUIIDING � A � � ��J � � CONSTRUC710N,ANDHEREBYAUTHORREAEPRESENTA7NESOF7HISCAUNTYTOENTERUPONTHE �Y yd1 �l.��a.�� ZABOVEMENTIONED PROVERTY POR INSPECTION PURPOSES. 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