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HomeMy WebLinkAbout16180 �'�i/d'''�G.`� CITY OF DIAMOND BAR � , _ ., ----��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES f�,��O��� w 21660 E.Copley Drive Suite 190 � PRESS ��"�9�°�` BUQ.DING PERMTT APPLICATION FIRMLY y JOBSITE /�j � � APPLICATION �'� PERMIT �`�n � QJ p P/C o ADDRESS ► "� DATE NUMBEFY �'" �>��� # $ ISSUE TYPE OCC APN LOT TRAC DATE CONST. GROUP p OWNER � ADDRE S ' ZONING SETBACKS � CITY �� � _ ZIP 7 EL. REART RW ❑❑ APPLICANT _ „� TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS , �� � PROPOSED USE � CITY ' ZIP � �TEL. o ARCHlENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS = CITY 21P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION � OOWNER-BUILDER DECLARATION SFR/ADDlREM p 1 HEREBV AfFIRM UNDER PENALTY OF PEiiJUflY THAT I AM EXEMPT FROM THE CONTRACTORS ll- G0f098/CdIp01f W CENSEUWFORTHEFq.IOWINOREAAON(SEC.7031.SBUSINESSANDPFOFESSIONSCODE:ANYCI7VOR (n U Ca1NTVWHIpiREWIRESAPERMITTOCONSTRUCT,/LL7ER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUP IW PetiO/DeCk WTURE.PRpR TO ITS ISSUANCE,AL50 REOUIRES THE APP4ICANT FOR SUCH PERMIT TO FI�E A$IGNED � STATEMENT 7HAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSELAW(CHAPTER9�COMMENCINQWITFISECTION70Do)OFDIVISION30FTHEBUSINESSANDPRO- � POOUSp2 FES4qNS CODE)ORIHATHE Ofl SHE IS EXEMPTTNEREFROMANO THE BASIS FOR THEALLEOED E%EMP- � TION.ANYVIOLATIONOFSECTION7031.6BV�NYAPPLICANTFORAPEPMITSUBJECTSTHEAPPLICANTTO Z Re-Root F ACIYIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(S5o0)J: � ❑I,ASOWfJEROFTHEPROPERTY,OPMVEMPLOYEESWITFiWAGE5A5THEIflSOLECOMPENSATION, � CO/f1ffIBfCIdI " WILL DD THE WORK,MI�THE STHUCTURE IS NOT INTENDE�OR OFFEREC FOR SALE(SEC.7oaa,BU51- J NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTYWFiOBUILDSOFIMPROVESTHEREON,ANDVAiO�0E5SUCHWORKHIMSELFORHERSELFOq = � THROUGHNISORHEHOWNEMPLOYEES.PROVIDEDTHATSUCHIMPROVEMEMSAFENOTINTENDE�OR m � OFFEREDL'ORSPLEIF,HOWFVFR,THEBUILOINOORIMPROVEMENTISSIXDWITHINONEYE4ROFCOMPLE- z TION,THE OWNER-BUILDER WIIL HAVE THE BURD9J OF PROVING THAT HE OH SHE OID NDT AI11LD Oq = IMPROVEFORTHEPURPOSEOFSALE�. ❑I,ASOWN[NOFTHEPROPERTY,AM EXCLUSIVELYCONTMCTIN6 WITH 410ENSED CANTRACTORS � TO CONSTRUGTTHE PR0.1EC7(9EC.70��,BUSINESSAN�PROFESSIONS CA:'1E:TNE CON7flACTORS U- V81UaliOn _ ADJ.AREA W CENSEIAWDOE5N0?APPLVTOANOWNEFOFAPROPERTYWHOBl11LDSORIMPROVE@THEREON.AND � WFIOCONTRACTSFORSUGHPR0.IECTSWIlHNCONTRACTOP(5)UCENSEDPURSUPNTTOTtriEWNTRAG QUANTITY DESCRIPTION FEE � TORS UCR15E LAW.�. O ❑IAM E%EMPT UNDER SEC. _ B.8 PG FOfl THIS REASON GJ( 3 _! U � �',' OpTE _._ OWNER U Z — W � LICENSED CONTRACTORS DECLARATION w � � 1 HEREBY AFFIAM UNDER PENAI.TY C�F PERJUPY hiAT IAM LICENSED UN�Efl PROVISIONS OF CHAPiER � , � 9(COMMENCING WITH SECTIOIV 7000)OF OIVISION 30F7HE BUSINESSAN�PROFESSIONS CODE AND Z MY IICENSE IS IN FULI fORCE AND EFFECT, m O �` �� � _ � LICENSE G S / IIC.NO. J U pATE,�„e!���E��.y�—_ CONTRAGTOR _ a _ W � "1' _ � WORKERS'COMPENSA?ION DECLARA710N � � I HEREBV AFFIRM UNDER PENALTY OF PERJURV ONE OF 7HE f-0LLOWMG DECLARA710NS: U � Z Q — � I HAVE AND WILL MAINTAIN A CER'71FICATE OF CONSENT TO SEIF-INSURE FOR WORKERS' 2 � COM$ENSATION,AS PROVIDED BY SECTION 3'70o OF TNE UBOR CODE,FOR THE PFRFORMANCE W Q '��f}1E N/�RK FOR MVHICH 7MIS PEflM1T IS ISSUED. � _I HAVE AND WILL MAIMAIN WQRICER$'CAMPENSATION INSURANCE,AS REQUIREO AY SECTION Q 3�ao OF THE LABOR OODE,FOR THE PERFORMANCE OF THE WORK FOP WHICH THIS PERMR IS ISSVEO.MY WORK 5'CO/y�PE �TIUY INn y{RANCE CARRIE N�P ICV NU RE: CONSTRUCTION � CAHRIER��""��'�+�-''� �/-�p� FLAN REVIEW _ � POLICYNUMBER���� � �1L ELECTRIC _ _ !. . � (IH�SSFCIY�NNF6)NO'tBECCMI'L�fE00FTF1EPEPM71Si'ORDNEFAN,DREDDOl1AR5(S1ao)OFiLESS). PLUMBING _ W i MECHANICAL � I CENTIFY THAT IN THE PERFOPMhNCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,i (,'} u^HALLNOTEMPIOYANYPERSONINANVMANPIERSOASTOBECOME5U8JECTTOTNE � WORKEfiS'COMPEN IONIAWSOFCALIFORNIA,ANDA6REETHATIFISHOUIDBECOME INSPECTIONFEE � SU&IECTT ?HE KERS'Ct1MPENSATIONPHOV1510N50FSECTtON3�coOFTHELABOR . — . CCDE,IS LLFO WITHCOMPLYWI HOY151oN5. �SSUAN O �� �p � p DATE: '� APPUCANT: — y -- . w ENERGY P/C ' "'� J WARNING FA URET SE RE WOFKERS'COMPENSATION COVEHAGE IS UNLAWFVL, ' � ' SUBJECTANEMPLDYERTOCRIMINALPENALTIESANOGIVIIFINESUPTOdJEHVNOFEDTHOUSAND ENERGYPER IT '� ._ OOLLARS(510D,OOD),INADDiI'IONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIOEDFORIN -����� � SECTION37080F7'HELABORCODE,INTEREST,ANDATfORNEV'SFEES. RETENTIONF � CONSTRUCTION IENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIflM UNDEFi PENALTY OF PERJURY THAT THEFE IS A CONSTRUCTION LENDING AGENCV __ FOR THE PEP W RMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUE��SEC.3oB7,CIV.C.). W � LENDEFYSNAME_ - � LENOER'SADDRESS � w IGERTIFYTHATIHP.VEREA�THISpPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � I qGREE TO CAMPLY WITH All CITY AND CAUNTY ORDINANC ANO STA:E LAWS REUTING TO BUILOING CONSTRUCTIUN,AND MEREBV AUTHORRE flEPRESENTATIY OF THIS COUN7V TO ENTEq UPON THE ZF90VE-MENTIONED VROPERTV FOR INS ECT N PURPOSE . COM MS � J � m PEAMI7TEE N 4 � v� /� _ � SIQNATVRE OF P AIITTEE � DA E = RECPLNO. PAIDBV _____ ____VALIDATION ~ WHITE—Department Copy,VELLOW--Finance Copy,PINK—Assessor Copy,GOIDENROD—Fie Copy.GREEN—App icanCs Copy ,�.L. j /►..1_��c.-�' , , ,.n,.,,. ,.,�y:.,. r,� ,; - r • �' s�Pr � ..p o- : ��.. � � 4'". Un.,'r..' ;�. .9,. N'DVY #N^i b y��a,�yT .. ... , .:;i,iF --'i�:.�ro . . .,q. p p�.y.... r' .'e.�'.e .,'.n:.::.+P . .,�;:: i� .} r . . '�` 4� fi, { 7f1 +717` . .r� .. .��R.";t�: .� � ,.'.k4ik�,� . ��°�"��' ��� ����°���� ���� �������`�`����� ���:�,���� � , , p „ w ����rt'�,`�` �' � ���"'� �a� �� � � "���a� .' , ��'' . 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