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HomeMy WebLinkAbout16455 (22) l ..----� CITY OF DYAMOND BAR � � --1� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES `��� � f,,_° _ � 21660 E.Coplcy Drive Suite 190 � � � ,, ;,,1 (909)860-3195 Fax(909)661-3117 , � PR�$S � ` �'p�' BUILDING PERMIT APPLICATION �F✓ FIRMLY �'� JOBSITE APPIICATION /�} � PERMIT P/C o ADDRESS DATE V NUMBER # � c�. ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER " ADDRESS�� ZONING SETBACKS �W CITY CA�.__g� ZIP •TEI.� ` REART RW p APPLICANT TEL. SIDE/SIDE STREET "RW ❑ �i CONTRACTO SIDE q �' AODRESS PROPOSED USE �`, CI ZIP TEL. ' • w ARCWENG/ ?. ; �,�,,�� � Z DESIGNER : NU.DWE�,L. �• NO. NO. � ADDRESS _ UNITS STORIES BEDROOMS � CITY ZIP TEL. N - DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ;- ¢ OWNER-BUILDER DECLARATION SFP/ADD/REM 0' ' I HEREBYAFFIHM UN�ER PENALT/OF PERJURY THAT I AM EXEMVT GROM'THE CONTRACTORS LI- GBfdJB/C8IpO1T �� liJ .CENSEIAWFOflTHEFOLLONPN�REA50N(SEC.7031.SBU91NE93ANDPROFESSIONSCpDE:ANYCITVOR � (n , (�: [.�` �_,COUNTVWHICHRC-0UIRE&APERMITTOWNSTRUCT,AITER,IMPROVE,�EMOUSH.OflREPA1RANYSTRUC W patio/�eck µ Z -NRE,PP1DR 70ITS ISSUANCE,ALSO RE�UIpES THE APPUCANT FOfl SUCM PERMI7 TO FILE A SIGNED ° W � �:S7A7EMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTOHS LI "-CENSE IAW(GHAPTEfl B(COMMENGIPIO WITF1 SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO u' PoOUSPd � ��FESSIONSOODE)OATHATHEOASHfiISE%EMPT7HEFEfROMAND7HEBA515FOR7HEA�LEGEDEXEMP-. --TION.ANVVIOtAT10NOfSECTION703t.5BYANVAPPLICANTFORAPEPMI75U81ECT5THEAPPLICANTTO - z R8-ROOf F 'ACMLPENALT'/OF NOT MORE THAN FIVE HUNDRED DOLLqqS(Ssao�.): ❑I,ASOWNEROFTHEPROPERTY.OHMYEMPLDYEESWITHWA6ESASTHEIRSOLECOlAPENSATIbN ' C]� COt17f718lCI8I - ' �_ .'WILL p0 7HE WOAf(,ANO TtiE STRUCTURE IS NOT INTENDED OF OFFEREO FOR SALE(SEC.7044,DUS4 x � � �,NESS AND PHOFESSIONS CODE THE CONTRACTORS LICENSE UW UOES NOTAPPlYTO MI OWNER OF 1 j ' -�PfqPERTYWFIUBUN.DSORNdPROVE5h1EREON,ANDWHODOEBSUpiWORKHIMSELFOqMERSELFOP � CL�.THpOUGHHiSOqHEROWNEMPIOVEES,PHOVIDE6THA75UCHIMPROVEMENiSARENO7INTENDE00R �- m �:_ �OFFEREDFOHSN_EIFHOWEVERlHE9UILDINGORRAPROVEMENi1550LDWITNINONEYfAROFCOMPLE- �- Z: �TIDN,THE OWNEq-tlUIlDE0.WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT BWID OP � _., _IMPROYEWRTHEPUflPOSEOFSALEJ. ' � ❑4�`OWNEfl OFTHE PROPEflfV,AM EXCLUSIVELY COMRACTING WITH LICENSED CONTRACTOftS �'`TO CONSTfiUCT TNE PNOJECT(3EG 70tA,BUSINESS AND PROFE9510N5 CODE:TF7E CONTfiACTOflS LI� = VfllUflfl011 ADJ.AREA . W�. CENSEUWDOEBNOTAPPLYTOANOVJNEROFAPROPERTYWHOBUIL�SORIMPROVESTHEFEON,AN� Si�-WFqCONTMCT6FORSUCHPqOlECTSWITNACaNTRNC70R�S{UCENSEDPUflSUnN7TOT1iECONTRAG .QUAMTIN DESCRIPTION FEE - . ~'' TORSUCENSEUW.1. �,,. ❑IAM EXEMPT UNDERSEG 8.�Ra FOpiHIS REASON � �� DATE OWNER V €� ` U ._..__.-- �-- W �Q LICENSED CONTRACTORS DECLARATION i j (t- .I HER�YAFFIRM UNDER PENALTY OF PERIURY THAT I NA LICENSEO UNDEfl VROVISIONS OF CHAPTER � . �_ �__ �Y(CQMMENC1IVCiW�TH5ECT10N7o00)OFDIYISION30FTHE6U31NESSANDPRO�[SSIONSCODE,AN� z �, �� MY LICENSE IS ItV FULL FORCE AND E ECT. 1� J�� m � � -UCENSE CLASS '/ ,LIC.NO. �I.1S'/� � � V DATE '� _CONTRAOTOf.=�.`I� __ _ ��� W � � WOFlKERS'GOMPEAJSATION DECLARATION —i ; � U � IHEREBYAFflRMUNOERPEt7ALNOFPER1UflYONEOFTHEFOILOWING�ECLAflATIONS: � � Q � _IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELf-INSUREFORWORKERS' = s COMPENSATtON,ASPFiOVIDEDBVSEC710N�7000FTNELABORCWE,foPTHEPERWRMANCE W oF THE WOPK FOR WHICH THIS vFAMI!IS ISSUE0. � � [�1J _I NAYEANO MlILLMAIMFW WORKERS'COMPENSATION INSURANCE.AS PEOUIRED BY 5[CTION 1 d- 37000FTN[tABOfiCODE,FORTH6P6RF-0RMANCEOfTHEWORKFORWHICNTHISPERMITIS / � - d ISSUED,MT' K�$S' PENSATqN Ifd5URM1C CAHNIERAND POLICY NUMBERAftF: CONSTRUCTION L �� I ` Q J C r/� "� ���/� @ � ? CARRIEP � [ .S�__ ____.._ PLAN REVIEW _ i � pOLiCYNUMeER {/ / ~(/J.L— ELECTRIC - ' —______..__ ------- ¢ Q (fFitSSEC11pNNE�NOTBEWF�I.E�EDOFiHEPEAA7TISFOROPIEFRHJ�REDDqlAAS�Stm)ORLESS� PlUM6iNG Z I GEflTIFYTHA7INT}iE Pf.RWRNANGE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (•J SHAILNOTEIAPLOYANVPERSONINANYMANNEpSOASTOBECOMFSl1AJECTTOTHE y� a.+'� ��•� � WORKERS'COMPENSATIONlAW50FGALlf-0RNIA,ANDAGREETHATIFISHOUL�BECOME INSPECTfONFEE 1 P '1 /I � Sll&IECTTO TNE VJOflKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR ._� ' . � CObE,fSHALLFORTMWITIHCOMPLYWI7HTHO5EPR0 i510 S.� ISSUANCE , p �ATE:��APPLICAN7. SMIP ._.. .._,.:--�..._._.., --..._,�� Q - : �- ENEPGY P/C . � WMNMG FAIW RE TO SEGl1qE 1YORKER3'COMPENSATION CAVERAGE IS UNUWFUI,AND SHALL BE � SU6JECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESt1PTOONEHUNDPEDTHOt15AN0 �NERGYPERMIT ��' � DOL.L.AHS(i100,000).IN PDDITION TO YF1E CAST OF COMPENSATION,OPMAGES AS PROYIDED FOR IN � 3ECTpNS7080FTHEUWRCO�E,INTEREST,ANDATfOqNEI"SFEES. RETENTIONFEE: O- CONSTRUCTION LENDING AGENCY PRE-ALT FEE: B��` CC' 1 HEREBV AFFIRM UNDEfl PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY ������-'�V�������"�� � FOR THE PERiOPMANCE OF THE WOflK FOP WHICH THIS PEFMIT IS ISSl1ED(9EC,9087,CIV.C.). - ' Z W �. IQJDER'S NAME_.___ #k � IENDEF'SAUORESS � . �..- Y � ICERTIFYTH7RIHAVEREADTHISAPPLICATIONANDSTA7ETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � �Gj n 1 � IAGREETOCOldPLYWITHAILCITYANDCOUNTVORDINANCE5AND5TATEL4WSRElATINGTOBUILDING CONSTFUCTION,ANDHEHEBVAl1THORRER PHESENTATIYESOFTHISCOIJNTVTOENTEHUPONTHE - ZAgOVE-MENiIONED PROPERTY F SPE ON PURPOSES. 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