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HomeMy WebLinkAbout17113 (26) CTl'Y OF DIAMOND BAR � ^- �``� -- DEPARTMENT OF COI��Il�IUMTY&DEVEL�PMENT SERVICES I 21825 E.Copley Drive T (909)860-3195 Fax(909)861-3117 _.,.. PRE$S �'���`�� BUILDING PERMIT APPLICATION FIRMLY JOBSITE APPLICATION PERMIT ((+ P/C,� o ADDRESS -� � � I�` DATE S��-/tI`Cl N NUMBER � ► {I # � ISSUE � i TYPE OCC APN LOT TRACT � � DATE I"( O � CONST. GROUP p OWNER ��i'�'i:1 /4!(i'i�Li o ADDRESS�+.�Z� C G� �i/'�'✓� ZONING SETBACKS z CITY 21P TEL. FRONT RW ❑ o APPLICANT 11 ot t"�� TEL. SIDE/S�DE STREET RW � z Q C ACTOR SIDE ❑_ � ADDRE PROPOSED USE � LCJ �C S � •v o� CITY ZIP TEL /j � �� �� � ARCH/ENG/ �r•"'L`�, e`��'�—� - - C-r'' iz DESIGNER NO.�WEL. NO. NO. � ADDRESS � CITY ZIP TE . UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/AEM O � I HEREBY AFFIRM UNDER PENALTV OF PERJIJRY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8fa9B/COfPOR W CENSEL4WFOR7HEFOLLOWINGREASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANVCITVOR (n U COUNTYWHICHREq11qESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W Pd�ip/DBGN Z TURE,PRIOR TO ITS ISSUANCE,ALSD REDUIRES THE APPLICANT FOq SUCH PERMIT TO FILE A SIGNED W STAiEMENT 7HRT HE OR SHE IS LICENSE�PURSUAN7 TO THE PROVISIONS OG 1'HE CONTRAC70R5 LI� W � CENSE L4W(CHAPTER 9(COAAMENCING WI'H SECTION 7oaa)OF DIVISIO�3 OF iHE EUSINESS AND PRO- � POOUSPd FESSIONSCODE)ORTHATHEORSHEISEXEMPTTFiEREfROMANDTHEBASISFORTHEALLEGEDEXEMP- (� � TION.ANYVIOLATIONOFSECTION7a31.58VANYAPPLICANTFORAPERMITSUAJECTSTNEAPPLICqNTTO Z Re-Roof A CNIL PENALTV OF NOT MORE THAN FlVE HUNDRED DOLLAqS(ESaa).�: � ❑I.ASOWNEROFTHEPflOPEFTY,OflMVEM7LOYEESWITHWAGE5A5THEIR50LECOMPENSATION, 0 COmrt10�C18I Z WILL DO THE WOPoC,ANO THE STRUCTURE IS NOT INTENDED OR OFFEREO FOP SALE(SEC.7044,BUSI- J � NE55 ANO PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF = ^ -y^n PROPERTY WHO BUILDS OR IMPROVES THEREON,ANO WHO DDES SUCH WOFK HIAASELF OR HERSELF OR C/4� � THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THATS'JCH IMPROVEMENTS ARE NOT INTENOED OR m 0 OFFEREDFORSALE.IF,HOWEVER,IHEBUiL01NGORIMPROVEMEN71S50L�W'�THINONEVEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAYE THE BURDEN OF PROYING TI IA7 HE OR SHE OID NOT BUI'..D OR � IMPROVE FOR THE PURPOSE OF SALE). W 71,ASOWNEROFTHEPROPERTY,AMEXCLUSNELYCONTRACTINGWITHLICENSEDCONTRACTORS `-.. [[ TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE THE CONTHACTORS U- VflIUdli0fl '� ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERT'WHDBUILDSORINPROVESTHEREON,AND � WHOCONTRFlCTSFORSUCHPPOJECTSWITNACONTRACTOR(S)UCENSEDPURSUANTTOTHECOMFAC- QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.�. � ❑I A�A E%EMPT 11NDER SEC. B.8 P G FOR THIS REASON J O V � � � DATE � `U OWNER � Z A���-. W � LICENSED CONTRACTORS CLARATION W Q (L IHEREBYAFFIRMUN�ERPENALNOFPERJURYTHATIAMLICENSEpUNOERPROVISIONSOFCHAPTE9 � � � 9�COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE&151NES5 ANO PROFESSIONS COOE,AND z w MY UCENSE IS IN FULL FORCE AND EFFECT m � LICENSE CLASS LIC.NO. y_ 4` � _ F J U DATE CONTRACT01i �� 0- W � WORKERS'COMPENSAtION DECLARATION Q � IHEREBYAFFIflMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: z Z ,I HAVE AN�WILLMAINTAINACERTIFICATEOF CONSENTTO SEIF-INSURE FOR WORKEFS' _ COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE IABOR CODE,FOR THE PERFORMANCE U ¢ OF THE WOFN FOR WHICH THIS PERMIT IS ISSUED. � � w _I NAVE AND WILLMA':NTAIN WORKERS'COMPENSATIDN INSURANCE,AS REOUIRED 6V SECTION p 3700 0F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 D ISSUED.MYWORKERS'COMPENSATIONINSUqANCECAPRIERANDPOLICYNUMBERARE�. CONSTR�JCTION � J j cpqRieq � PLAN REVIEW 2 POLICV NUMBER ELECTRIC 4 � (iHISSECTIONNEmNOTBEOJMRETFDOFTHEPERMITISWRIXJEF0.1NDF7E0Di7L1AR5(57oD)ORlESS). PLUMBING Z I CERTIFV THAT IN iHE PERFORMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED,I MECHANICAL (J SHALL NOT EMPIOYANY PERSON IN ANY MANNER SO AS TO BECON�SUBJECT TO THE � WORKERS'COMPENSATION LAWS OF CAUFORNIA,ANDAGFEE THAT IF I SHOULO BECOME INSPECTION FEE � SU&IECTTOTHEWORKERS'COMPENSATIO ROVISION FSECilON37ooOFTHEIABOR CODE.1 SHALL FORTHWITH COMPLY WITH T SE PRO IONS. i ISSUANCE � �' � � � 0 DATE: � "'� I<� APRICANT: SMIP �._— j WARNING�FAILURETOSECUREWORKERS'COMPENSAT:ON VERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C � SUBJECTANEMPLOVERTOCRIMINA�PENALTIESANOCIVI NESUPTOONEHl1NDREDTHOUSAND ENERGVPERMIT DOLLARS(5100.000�.IN ADDRION TO THE CDST OF COMPENSATION,OAMAGES AS PflOVIDE�FOR IN aSECTION 3708 OF THE LABOR CODE,INTEREST,AND AT70PNEYS FEES. RETENTION FEE: d GONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � � I HEREBYAFFIRM UNDER PENALTY OF PERJUflY THAT7HERE IS ACONSTqUCT10N LEND'�NG AGENCY _ _ FORTHE PERFORMANCE OFTHE WORK fOR WHICH THIS PEflMIT IS ISSUED(SEC.3�97.CIV.C.). 2 W � LEN�ER'S NAME F— LEN�ER'SAODRESS _ ___ /� � ICERTIFYTHATIHAVEREADTHISAPPLICATIDNANDSTATETHATTHE�BOVEINFORMATIONISCOPRECT. TOTAL FEES /V f �/� � IAGREETOCOMPLYWITHALLCITYANDCOUM1TYORDINr1NCE5ANO5TATELAWSFELATINGTOBtIILDING � (� � CONSTRUCT!ON,ANO HEREBY AUTHORIZE RE?RESENTATNES OF TNIS COUNTV TO EMER UCON THE Z ABOVE-MENTIONEO PPOPERTY FOR INSPEGTION PURPOSES. COMMENTS O �` � +�l ¢ PERMITTEE NAME(PFINn � � ' _l<'„� (/� SIGNATUREOFPEflM DATE = RECPT.ND. 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