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HomeMy WebLinkAbout16422 (23) s CITY OF DIAMOND BAR � �� � �.... --- "����'— DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES f � rj� 21660 E.Copley Drive Suite 190 t Q l`' (909)860-3195 Fau(909)861-3117 PRESS �"�^ BUTLDING PERMIT APPLICATION FIRMLY o DDRESS � C�L ' � #L DATECATION �r ���vl Nl1MBER�'��P/C _ . # � ISSUE TYPE OCC -- APN OT TRACT ' �� , � ik E.. DATE CONST. GROUP o OWNER �S � ADDRESSS�}�E �-S � ZONING SETBACKS 0 � CITY ZIP TEL._ � FRONT RW � APPLICANT � E�• SIDFJSIDESTREET RW C � CONTRACT R •L.f✓7 yS SIDE ❑ ADDRESS � CITY - 21P��'Z, TE '^Z � PRUPOSED USE o ARCWENG! z DESIGNER NO.OWEL NO. NO. � ADDRESS UNITS STORIES BEDRQOMS � CITY ZIP TEL. � u� DESCRIPTION SGl.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA110N $FR/ADD/REM O p I HEqE9Y AFFlRM UNDER PENA4T'OF PLRJURV THAT I AM E%[MP?FROM THE CONTPACTORS LI� G8fd9B/Ce�()Oli I1J CENSEIAWFORTHEFOLLOWINGREASON(SECJo37.58USINESSANDPqOFESSIONSCODE:ANYCITVOR (n � COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALT�R.IMPROYE.DEMOLISH.ONREPAIRNJYSTRUC- W PetiO/�BCk TURE,PRqR 70 ITS ISSUANCE,ALSO REQUIRES 7NE APPLICM'T FOR SUCH PERMI7 TO FILE A SIGNE� W STATEMENT THAT HE OR SHE IS LICENSEO Pl1R5UANT TO iHE PROVISIONS OF THE CANTRACTORS LI. W � CENSE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)CF DIYISION 3 OF THE 9USINE55 AND PRO� � POOVSpd FESSION6COOE�ORTFiATHEORSHE�SEXEMPT7HEREFflOMANDTHEBASISFORTHEALIEGEDEXEMP. 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O ❑IlUqEXEMPTUNDEFSEC.,.__.________B.BP.G.FORTHISREASON Q � � ��� U � � DAtE OWNER� _ __ � � LICENSED CONTRAC70RS DECLARATION ^ W I HEREBV AFFIRM UNDER 7ENALTY OF PERIURY THAT I AM LCENSED UNOER PROVISIONS OF CHAPTFR � � Y.9 �!,� P_ n r y� } � 9(GOMMENCINOWiTMSEGTYJN7000)DFOIYISIONJOFTMEBUSINESSANOPROFESSIONSCODE.AND ��V L C" {s"V' X� MY IICENSE IS IN FUL(.FORCE AN�EFFEC7. ' m 41 � �}�� � UCENSH C S ���LIC.NO.q��.J 7 7��� � � I V �ATE_��� CONTRAC70R%''./�—�_ ` a w � WORKERS'COMPENSATION DECLApA710N Q � U � IHEHEBYAFFIHMUNOERPENALTYOFPERIURYONEOFTHEFOLIOWINGDECIAFATIONS: � 4 _I HAVEAND WILL MAINTAIN ACERTIFlCATE OF CA,ySENT TC SEIf-INSURE fOF 4VORKERS' S YQ COMPENSATKKJ,AS PRO4iDEU&V SECTION 3)W OF THE 1A80R CODE,FOR'HE PERfOF1MANCE W tlF TME WORN Ff)R WHICH THIS PFRMIT IS ISSUEO. Z � � __„_IHAYE�NOWILLMWNTAWWORKERS'COMPEN5ATIDNINSURANCE,ASPF.QUIqEDBYSEGTION Q 37a00F7HELAHOflCAOE,F'ORTHEPERfaRMANGEOFTH�WOFlKFORWHICHTh!ISPERMI7'IS ISSUED.M'!WORK 'COMPENSATION INSURANCE CARHIER.WD V LICV NUMBER ARE: CONSTRUCTION ¢ .� . � {�����-_ �, CARRIER_ �� .-�"I+ PLANREVIEW QL roucvrauMeeq � . ELECTRIG _ d �0 (RAGS'eCTYJN4e.FDNOTBEWMPLEfmOFTNEPEPAIRSFGRO.'J&IiUrDREDWl1ARS($100JORLE55). P�UMBING � W Z' ICERTIFVTHATI4THEPEAFORMANCEOF'fHEWOP�NFORWHICHTHISPERMI715155UED.l MECHANICAL „ ___ '� SHALlNOT EMP�OY ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE � WORKERS'CCMIPENSATIONUWSOFCAUFORNiq,ANOAGREETHATIFISHOULOBECOME INSPECTIONFEE � SU&IECTTOTHERORKERS'COMPENSATIONP�OV'�SION50F5ECTION37o00FTHELHBOR ` CODE,I 4ALL F RTXWITN COMPLY YVITH!TH�dO E PROVISIONS. ISSUANCE �1 � �f y�/�� p DATE:���-11 APPLICANE ���4=_ � _ SMIP _ _ J WAHNMGFhILURETOSEGURENlORKERS'l7JMPENSqiION('AVEflAGEISUNLAWFUL,ANOSHALLBE ENERGYP/C LL, SUBJECTANEMPLOYERTOCRIMINALPENAI.TIESANpCIVILFINESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT OOLLARS(Si00.OW).IN ADDITIpM TD THE COST OF(X1MPp.�SATION,DAMAGES q5 PROVI�E�FOR IN � SECTION3]a80FTMELaBORCO�E,INTEREST,NNDATTORNEI"SFEES. RETENTIONFEE: _ a CON57RUCTION LENDING AGENCY pRE-ALT FEE O � 1 NERE9Y AFFIRM UNDER PENALTV OF PERJURY THATTHERE IS A CONSTRUCTION LENOING AGENCY __ FON TME PEftFORMANCE�FTHE WOPK FOR WMICH TFiiS PEFMIT IS 195UED(SEC.308I,CIV.C.). Z iLl �T- LENDER'S NAME _ � H LETAJER'SADDRE55 � TOTAL FEES ��O.�U � � :.J � I CERTIFYTHAT I HAVE READ THIS APPlICA710N AND STATE THATTHE ABOYE INFORMATION IS CORRECT, W IAGPEE70C0lAPLVWITF{AILpTYANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOB:IILDING � CONSTRUCTION,ANDHEAE6YAUTHORIZEREPqFSENTATNESOFTMISCOUNTYTOENTEftI1PON'ME Z ABOVE-MENTIONED CRpPERTY FpR INSPECTION PURPpSES. 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