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HomeMy WebLinkAbout15931 (20) ���_ CITY OF DIAMOND BAR ����� �•+ - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES f - W 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRES$ � ��� � BUILDING PERMTT APPLICATION FIRMLY � JOBSITE , �/y� / �-�/� APPLICATION � � � PERMIT P/C o ADDRESS���>9Cf" (c�'c�'"+�'����r�J"!G� -����`'�� DATE NUMBER il c� ISSUE TYPE OCC APN LOT TRACT--� _ pqTE CONST. GROUP g OWNER .�'�G�� . /S�r'�.._...y�'.?�'J5-C'J "" ADDRESS .`- � G-°C .� ZONING SETBACKS 0 � CITY "'7 yZIP TEL. � REART RW ❑❑ APPLICANT TEL. � SIDElSIDE STREET RW ❑ CONTRACTOR R'`�'�/ ��.�TA/-'�`` SIDE ❑ � A�DRESS � - �` ` d- _ CITY ZIP� TE� r aEs PROPOSED USE �J t:% � � ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFR/A��1REM O � I HER�Y AFFIRM UNDER PENALTY Of PERIUFlY THAT I AM EXEMPT FROM THE CONTRACTORS LI� G2fflJB/C8�]Ort CENSELAWFORTHEFOILOWINGREASON(SEQ70a1.56U51NE5SANOPPOFESSIONSCODE:ANVCITYOR (/? COUNTYKHICHREWIRESAPERMITTOCONSTRUCT.AL7ER.IMPROVE.�EIAOUSH,ORREPAIRANYSTqU0. IW patiolQOCk lt1RE,PRIOR TO 1T9 ISSUANCE.M59 REOUIRES THE APPLICAN7 FOR SUCFI PERMIT TO FIIE A SIGNED � 6TATEMENT IHAT HE OR SHE IS UCENSED PUHSUMff TO YHE PROVISIONS OF THE CONTMCTORS U- � CENSEUW(CHAPTERe(COMMENCINoWITHSECT�ON70uo)OF�IVISION30FTHEBUSINESSANDPRO� � PoOVSpa FESSIONS CODEJ OR hIAT HE OR SHE IS EXEMPT TIEREFROM ANO h1E BASIS FON THE AIIEGED EXEMP- TION.MIYVIOLATIONOFSECTIOH7031.6BYANVAPPUCANTFORAPERMITSU&1ECTSTHEAPPUCANTTO z Re-Roof � ACIVILCENALTYOFNOTMOilETNANFIVEHUNDRED00LLAfiS(S5o0)): � �I,ASOWNEROFTNEPROPERTY,ORMYEMPLOYEE3WITHWAGESASTHEINSOLECOMPENSATION, � COfItrtlOfCiel . - WILI DO THE WORK,AND 7HE STRUCiURE IS NO7 INTENDED OR OFFERED FOF SALE(SEC.7oM.BU51� J NE33 AND PROFESSIONS CODE:THE CANTRACTORS UCENSE LAW�OES NOTA7PLV TO AN OWNER OF � PROPERTVNRiOBUILOSORIMPp�VE57HEREON,ANDVM1iODOESSUCHWORKH!MSELFORHERSELFOR � CL THMUGHNISOflHEROYJNEMPLOYEES,PROVIDEDTHATSl1CHIMPqOVE4ENTSAAENOTINTENDEpOH m LJ� OFFERED�ORSALEIF,HOWEVEF,THEBUILDIN�OHIMPROVEfAENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILDER MAIL HAVE THE BURDEN OF PROVING iHAT HE OR SHE DID NOT BUIL�oq � IMVROYE FOR'THE PURPOSE OF 5M.E1. ❑I,ASOVMER OF TFiE PROVER7V,NA EXq.USNELV CONTRACTING W!TH UCENSED CONTRACTORS � TO CONSTRUCT THE PR0.IECT(SEC.7a44,BUSINESS ANO PROFESSIONS CODE:THE CONTRAGTORS LI- V8W811Df1 __ __ ADJ.AREA W CENSELAWDOESNOTAP7lYTOANONRJEROFAPROCERTYWHOBUILDSORIMPROVESTHEREON,AND � WrI00DNTMCT5FOR5UCMGRQIECT3W11}1ACONiRACTOR(S)�ICE4SEDPURSUANTTOTHECONTRAG (}UANTITY DESCRIPTION FEE � TORS LICENSE LAW.�. ❑I AM EXEAIPT UNDER SEC. B.6 P.C.FOR THIS FEASON J LL � �ATE ____'�OWNEfl_____' _ � W � LICEN3ED CONTHACTORS DECLARATION �j � I HEREBY�FFIRM UNDEP PENALN OF PERJUHV 1HAi I AM IICENSED UN,?ER PRONSIONS OF CHAPTER � � B(COMIAENCINOWITHSECTION7o0o)OFDIVISION30FTHEBUSINESSAN�PF�FF.SS!ONSCOOE.AN� � x_x MY LICENSE IS IN FULL FORCE AND EFFECT. m 0 LACENSE CLASS LIC.NO. � V pATE_ CONT�AC70R J__ �- W � WOAKERS'COMPENSATION DECLARATION Q , . .. � I HEREBV AFFlRM UNOEfl PENAL7Y OF PERJURY ONE OF THE FO4LOW:NG DECLARA710N5: U � � Z Q � ,IHAVEANDWILLMAINTAINAi.ERTIFICATEOFCANSEMTOSELF-INSUFEFORWORKERS' 2 �� �Q-r COMPENSATION,ASPflOVIDED@YSGCTION3]ODOFTHEl.A80RCODE,FORTHEPEHFORMANCE `U � OF 7ME WORK FOR WIHICH THIS GERMIT IS ISSlJEO. � � '�I H�AVEAND WILLM�.INTAIN WORKER5'CAMPENSATION INSURANCE,AS REOIIIRED 9V SECTION ! M ��,e TJ QQ � 370oOFTHELA80RC6DE,FORTHEPERFORMA�CEtJFTHEWORKFORWFIICHTHISPEflMIT15 �D �}' u�' � Y ISSUED.MY W Bi(ERS'COMPENSATION INSUPANCE CARPoER ANO POLICY NUMBER ARE: CONSTRUCTIOf$-�U.{J�,.�TAi� A'T C��,LT 1 �T � CARRIEH__s����^''��G'L/��-T.� PLANREVIEW � PqL�CYNUMBEfl�� �"�� c _�.— ELECTRIC Q � (iHl&S6CIKNJNE�N6TBECJMPLEhbOF'f1iEPEi7ATISFORQI'E11lNN�REDD01.lAR5(S10o)ORLESS� PLl1MBING W I CER7IFVTHAT W 751L PFRFORMANCE OFTHE'NORK FOR WHICH THIS GERMIT IS ISS�ED.I MECHANICAL Z (,� SIiALL NOT EMPLOY ANV PERSON IN ANY MANNER SOAS TO 6EGOME SUBJECT TO THE � WORKERS'COMPENSATIONL4WSOFCALIFORNIA,ANOAGREETNA71FiSHOULDBECOME INSPECTIONFEE _-- - — �___i�.� � SU0.IECTTO'CHE YdJRKERS'COMPENSATION PROVISIONS OF SECTION J7oo OF THE LABOR r A CODE,�SHALLFOiiTHWITNCOMPIYWIiHTHOSE ISSUANCE � ;"�' O �'y� p DAT@.''/�~�� '�'�C'�APPLICANT: SMIP _ 1 d-�� w y ` ENERGY P/C J WARNINGFAILURETOSECUFEVJOFIKERS'COMPENSATIO VEflAGEISUNLAWFUL,AN�SHALLBE �y SUBJECTANEMPLOYER70CRIMINALPENALTIESAN�CIVILFMESUP700NEHUN�FEDTHOUSA� ENERGYPERMIT DOLLARS(f700,0001.IN ADOITION TO THE COSTOf COMPENSATION,DAMAGES AS PROVIDED FOF IN ¢ SECTION3�CBOFTHEUBOPCOOE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PR[-ALT FEE: O � I HEREBV AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FORTHE VERF�RMANCE OF THE WORK FOR WHICH THIS GERMIT IS ISSUEO(SEC.3oB�,qV.C.), Z W � � LENDER'S NAME _ h_- IENDER'SAODRESS g TOTAL FEES � � �,,,��C� � I CLRTIFY THAT I NAVE READ THIS APPLICATION ANO STATE THAT THE ABOVE INFORMRTION IS CARRECT. d 1 AGREE TO COMPLV WITH ALL dTYAND COUNTV OPDINANCES AND STATE UWS RELATING TO BULDIUG � CONSTRUCTION,AN�HEREBYAUTFiORRE REPRESENTATIYES OF THIS COUNTV TO ENTER UPON 7HE Z ABOVE�MENTIONEO PROFER'TY FOR INSPECTION PURPOSES. COMMENTS � �'/��.:..� /�,'��e'".�Y--n-.�„":L � — m PERMITfEENA !C ) /�/ �^ C/l ' ,_.1�.►w....G-� J "��`�� (n �SIGNRTUflEO PERMfTT DATE � RECPT.NO.__ _ ___,PAID BY ` VALIDATION WHITE—Deparirnent Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOIDENROD�--File Copy,GREEN—ApplicanYs Copy , , .. , ,� . , _ , . , b�., � _. � ������ �� ��:������� ��� �������,�'�"� �� ��:���. ��� ,:� „ � � -- �`„�:���,���;�`f�a��a R�� �ffi �:.� �,� "+ �� � � '�ax'�- ��.:: «�a`�:�; �a���:::��",� ���r . � • � ���t� ; ��. ;� �� � t �,"� �� � �. � �: � �� , � � ��_ � 9z�� �: � � � - �a� �'�.'�'��.�,r„.�°�".�x�:.„�����'" . _�`� . ._' . ��,�'�..� �,���.� : C;.f� .... ,�4...w.���� ��r���i��� , �(�a„��.. � ...m��� . ' y ._.._i C��t a� � . .� i . : �_'�. 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