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HomeMy WebLinkAbout16397 (22) . �� �;��� ; _�� _ CITY OF DIAMOND BAR w— , f DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES rG' �v�0� _ w 21660 E.Copley Drive Suite 190 ,,,,�,....; (909)860-3195Fax(909)861-3117 ��%�� PRESS BUILDING PERMIT,APPLICATION FIRMLY .: o DDRESS I �� � ��`C�'� ����S K- • DATE CATION ' �� C.� NUMBER�``��� #/C � APN LOT TRA_�yT �SSUE ' 9 � I-a� TYPE OCC DATE�� 4� CONST. GROUP p OWNER C�.f%F(�.C� 1¢C�SHl4 . o ADDRESS �A3 CC_ �ti S � � ZONING SET'BACKS � CITY ..d��'/L`h ZIP �XS TEL�Q�/-J�'' ' 377 REAR RW ❑ APPUCANT TEL. SIDFJSIDE STREET RW p � CONTRACTOR ��" C f__ SIDE ❑ � ADDRESS ?_- /'ssf �= d a CITY lt+.fF� ZIP �*S'TEL. l�t'7-�L-� PROPOSED USE A-TL L1-T'� J� � AACH/ENG/ ��,, DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS = CIN ZIP TEL. v� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILAER DECLARATION SFFl/ADDlREM O p I HEREBY AFFlflM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gaf89B/CeR1ol� 11J CENSEUWFOR7HEFOLLOWINGNEASON(SEQ7031.58USINESSANDPROFESSIONSCA�E:ANVCITVOR (n ZCOUNT`/WHICHREOUIRESAPEFMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,ORREGAIRANYSIRUC- W PdilO/DeCk TURE,PRIOR TO ITS ISSUANCE,AlSO REW IRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED «� STATEMENT THAT HE Oii SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CQNTRACTORS L6 W � CENSE UW�CHAPTER 9(COMMENCINO WITH SECTION�ODO)OF�IVISION 3 OF THE BUSINESS AND PRO- � POOUSPd FESSqN5CO0EJORTHATHEOR5HEI5E%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (� TION.ANYVIOI.ATIONOFSECTION70.41.6BVANYAPPUCANT�ORAPERMITSU&IECTSTHEAP7LICANTTO Z Re-Roof � ACMLVENAL7YOFNOTMORETHIWFIVEHUNDREQDOLIARS(5500).�: g ❑I.ASOWNEROFTHEPROPERTY.ORMYEMPLOVEESWITHWAGESASTHEIRSOIECOMPENSATION. ❑ Commerciat - MfILL DO THE WOAK.AND THE STRUCTURE IS NOT INTENOED OR OFFERED POR SALE�SEC.7oAd,AU51� J � NESS AND VfiOFESSIONS QODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLYTO AN OWNER OF � PROPERTV WFiO BUILDS OR IMPROVFS IHEREON,ANO WHO DOES SUCH WpRK HIMSEL�OR HERSELF OR CC 7HHOU6H HIS OR HEROWN EMPLOYEES,PROVIDEO THATSUCH IMPPOVEMENTS ARE NOT INTENDED OR m � OFFEREDFORSPLEIF,FIOWEVER,TNEBUI4DINGORIMPHOVEMBiTISSOLDWITNINONEVEAROFCOMPLE- z 710N,THE OWNER�BUILDER N7LL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILA OR = IMPRDVE FOR THE PURPOSE OF SALE�. w ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSNELVCONTMC7INGWIi}1LICENSEDCANTRACTORS � TO CONSTRUCT THE PRWECT(SEC.70L4,BUSWESS AND PROFESSIONS CODE:THE CONTRACTORS L!- VelUati00 ADJ.AREA W CENSEUWDOESNOTAPPIYTOANOWNEROFAPROPERTYWHOBUILD50RIMPROVESiHEREON.AND — — � Nh1000NTRACTSFORSUCHPR0.IECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAa QUANTITY DESCRIPTION FEE � TORS LICENSE LAW). � �I AM EXEMPT UNDER S�C. 3.8 P.0.FOR TrIIS REASON Q U W � DATE OWPtCp H' 0 W �s{ LICENSED CONTRRCTORS L�ECLARATION W CL I HEREBYAFFIHM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDEFi PROVISIONS OF CHAPTFR ,/ a. B(COMMENCINO NAhi SECYKKJ 7a0o)OF DIVISION 3 OF THE 9USINESS AND PHOFESSIONS CODE,ANO Z L✓T/� I��-Tr� � X MY LICENSE IS IN FULL FORCEAN FFECi. �7 � UCENSE CLASS �� LIC.N0. • ���C� � � '�`� /� V DATE��(�_ CONTRACTOR_�`�� C1- r � W � WORKERS'COMPENSATION DECLARATION Q � i HEREBV AFFIRM UNDER PENALTV OF PERJURY ONL Of THF.FOLLOWING DECLARATIONS: Z � _IHAVEANDWILLMAINTAINACERTIFICATE6FCf�NSFNTTOSELF-INSl1REFORWORKERS' ¢ 2 CAMPENS,4 , S PROVIDED BV SECTON 3?OOOF THE tABOR CADE,FOR THE 7ERFORMANCE W � OF ORK FOR WHICH 7F215 PEflMIT IS ISSUEO. � � �IHIIVEANDWIU.MAINTNINWORKERS'GbM?ENSATIONINSURANC,ASAFQUIREDBYSECT�N Q 37000F7HElA6 FORTHEPERfOR FT W FOPWHICNTHISPERMITIS ISSUED.MY WO ERS' �MPENSA710N INSU � CA i� D POLICV NUMBERARE. CONSTRUCTION � CMAIER__`__�� �.,�— ' � PLAN REVIEW 7 J/f.ii-� 1���� � POLICV 11UMBEF ELECTRIC _ —��••-ra Q � (fHISSECTI�NNEDNOTBE�OM1IPLETEDOFTF�PERMTtSFORONF.FNADRED ($100)ORLESS�. PLIJMBING _ � Z I CERTIFYTHAT NJ TNE PEflFORMANCE CF THE WORK F HICH THI PE 1A IS ISSUED,I MECHANICAL � SHALLNOT EMPLOYANY PERSON IN ANY M S EECO V6 T TO THE � WOFKERS'COMPFNSATiONLAWSOFCALi pNl IF�SH L�PECOME INSPECTIONFEE � SUBJECTTOTMEWOfiKERS'C01.9PENSATI NPR ON37 OF7HELABOR COUE,I ALLFOR7HWTHGOMPLYWITH HO IS�O . ISSUANCE � o ��r � OATE� APPLiCANT: SMIP J WARNIN6:FAIIUAE TO SECURE WORKERS'COMPENSATIO ERA�E IS UNLAWFUL,AND SHALL BE ENERGY P/C ____ � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANpCIVILFINESUPTOONEHUNOREDTHOUSAND ENERGYPERNIIT OOLLARS(S�Oo.00O).IN MDITION TO THE COST OF COMPENSRTION,DAMAGES AS PHOYIDED FOR IN � SECTION37080fT}IELA80RCOOE,INTEREST,ANDATTORNEY'S=EEs. RETENTIONFEE: Ow.. CONS7RUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDERPENALTYOFPEftJUHYTHATTHEREISACONSTRUCTIONLENDINQAGENCY _ FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3o9'!,CIV.CJ. Z w — �Z LENDER'SNAME S � IENDER'SADORESS _ � TOTAL FEES . �� � I CERTIFY THAT I HAYE READ TNIS APPLICATI 0 STATE THAT THE ABOVE WFORMATION IS CARPECT. � I A6PEE TO COMPLY WITH ALL CITV AND NTY ROINANCES AND STATE LAWS RELATNG TO BUILDING � CANSTRUCTION,AND FIEREBY AUTHORIZ REPRE ENTATIVES OF THIS COUNTY TO ENTER UPON THE Z PBOVE-MENTbNEDPflOPERTYFO CTqN URPOSES, COMMENTS � �'�.�'/f r� � ¢ PERMITfEEN � _ 1/'/?-°_� Uj SIGNATUREOFPE ITTE DATE = RECPT.NO. PAID BY VAIIDATION ~ WHITE—Cepartment Copy,YEILOW—Finanoe Copy,PWK—Assessor Copy,GOLOENROQ-File Copy,GREEN—ApplicanPs Copy ,�, , . ..,,. , . w,,.,- . ....„ , ���� �� ��;������� �� ����.���������� ����`��� . � ��r °� �� � ,. � �.� �� � ��mpp�� ���a°� . p ��� pS?§� �P ���:.s� �'�'*u+"�� � � � � .,:���&�3� ^�.4:� �� � e ""L �� �� �.� 3" � � k� � -"y.�' L{t»ff�.d ���`""'w�� � �. .. �.:�z, �..n� � �� . ."� �.. .x � ^y "�'�3 ��"y � �.�.. �a. ..��x � '�•�... �°�s:„�.... ���'�'t�' t e �F j fi4 �8 . 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