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HomeMy WebLinkAbout10614 l � '� C1TY OF DIAMOND BAR / COMMUNITY DEVELOPMENT DEPARTMENT _ 21660 E.Copley Drive Suite 190 PRESS (909)86Q3195 Fax(909)861-3117 � """°� UILD G PER PPL Tiorr FIRMLY o ADDRIES3 'Z�'�'L "7 ��T�-" � DATEICATION `7 NUMBER ��� #/C � � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNER D'AhV`.c;���—_-�-�-► 11��.JG._ L.trC "" ADDR SS �'L� i�-f C.- ( r . ` ZONING SETBACKS � z CITY �` : - 21P Z��'�' TEL.;�I� � � FRONT RW f.l. � APPLICANT _ �77CGWd4 Ei cy. TEL.• . .L Z Q REAR ❑ � o SIDE/SIDE STREET RW CJ � � CONTRACTOR SIDE ❑ Q ADDRESS PROPOSED USE 0 CITY ZIP TEL. w ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER•BI:ILDER DECLAHATION SFR/ADDlREM O � 1 NEREBY AFFIRM UN�ER PENALTY OF PERJURY THFT I AM EXEMPT FROM THE CANTRACTORS LI� GBf996/Ca�10H W CENSEUWFORTHEFOLLAWINGREASON(SEC,7o91.5BU5ME55AN�PROFESSIONSCO�E:ANVCITYOR (n U COUNTYWHICHRE�UIRESAPERMITTOCONSTRl1CT,ALTER,IMPROVE,OEMOLISH.ORPEPAIRANYSTftIIC W PafiO/DBCI( wT1qE.PRIOR TO RS ISSUANCE,ALSO REOUIRE9 THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNEO W STATEMENT THAT HE OR SHE IS UCENSED PUHSUANT TO THE PROVISIONS OF 7HE CONTRACTORS ll- �` � CENSE lAW ICNAPTER e�fAMMENLIN�WITH SECTION 7oDo)OF DIVISION 30F THE BUSINESS AND PRO� ' V' POOUSP8 7� FESSIONSCODE)ORTHA7HEORSHEISEXEMPiTHEfiEFHOMIAND7HEBASISFORTHEALLEGEDEXElAP- (� VTION.pNYVIOLATIDNOF3ECT10N7031.5BYANVAPPLICANTFORAPERMITSU&IECTSTHERPPUCANTTO Z Re-Root � � A CIVII PENAL7Y OF NOT MOPE THAN FNE HUNDRED�OLLARS(55oo).j: 0 UI,ASONMEROFiHEPROPERTV.ORMVEMPLOYEESWITHWAGESASTMEIflSOLECOMPENSATION. . � COfnm8fCi8I Z WILL DO THE WORK,AND TNE STRUCTURE IS NOT INTENDED OR OFFERED FOF SALE(6EC.701�,BUSI- J � NE55 ANO PROFESSIONS CODE�THE COHTflACTONS LICENSE IAW OOES NOT FPPLV TO AN OWNEH OF � PpOPERTYNh108UILD50RiMPROVESTIIEREON,ANDN710D0E55UCHWORKHIMSELFORHERSELFOR � � � THFd1GHHISORHERONMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAqENOTINTENDEDOR . LO W OFFEREDFOR&/1LE.IP,HOWEVER.THEBUIL�INGORIMPROVEMENTISSOIDWITHINONEYEAflOFCAMPIE- � TION,1'HE OWNfR-fiNLDER WILL HAVE THE W R�EN O;PROVING TIfAT HE Ofl 3NE DID NOT BU�tD OR � Z IMVflOVE FOR THE PUflPOSE OF SALE). � W ❑I,ASOWNEFOFTHEPROPERTV,AMEXCLUSIVELVCONTRACTINGWITHLICENSEDCONTPACTORS WTO CONSTRUCT THE PFOJFC7(SEC.70/a,BUSINESS qND PROFESSIONS CADE:THE WNTRACTOHS LI� V81U9�iOf1 _ ADJ.AREA CENSEUWDOE9NOTAPPIYTOANOWNEROFAPROPENTVMIHOBUIL�SORIMPROVE6THEREON,AND - � � VhiUCONTRACTSFORSUCH7RQIECTSWITHACONTRACTOR(S)LICENSEOPIIR5UANTTOTHECONTRNG QUANTITY DESCRIPTION . FEE � TORSLICENSELAWJ. �— �' _B.8 P.C.fOR 7HI5 REASON J O n I AM E7(EMPT UNDER SEC.�.__ , � � � — _ ~� 1 ____ � � OATE �_OWNER L�� - U � Z W � LICENSED CONTRACTORS DECLARATION � W � I HEREBVAFfIPM UNDER PENALTYOF PERJURV hIAT IAM LICENSED UNDEfi PROVISIONS OF CFIAPTER � �. d' B�COMMENCINaWITHSECTION7a00�OFDIVI510NlOFTHEBUSINE55ANDPflOFESSIONSCODE,AND Z �X MYLICENSEISMNLLfORCEANDEFfECT. - m � UCENSE CLASS LIC.NO. � ~ J V �ATE _ _CONTHACTOR .___ : a W 4 �. WORKERS'COMPENSATION DECLARATION ,, Q a � � � � INENEBYAFFIRMUNDERPENAL7YOFPERJURYONEOF7HEFOLLOWINGDECLAHATION9', �' Z �� � _INAVEANDWILIMAtNTAINACERTIFICA7EOFCONSEMTOSELF�INSl1REFORWORKERS' � _ ' � CAMPENSAiIDN,ASPROVIOEDBYSEcilON9�ooOFTF1ELA80RCODE,FORTMEPERFOHMr1NCE `U OF THE WOHK FOR WMICH hIIS PERMIT IS ISSUED. � � � W __,_i HAVEAN�WILLMAINTAIN WORKERS'COMPENSATIDN INSURpNCE.RS REOUIREO BY SECTION Q 37000FTHELABORCWE.FOH7HEPERFORMANCEOFTHEWORNFOflWHICHTHISPEflM1T15 ISSUEO.MY WOFKERS'COMPENSATION INSUMNCE CARRIEF AND PoLICY NUMBGR ARE: CONSTRUCT�ON 1 � j CAflR1ER_ _._ _ PL4N REVIEW _ � z,, POLICVNUMBER�_ __ ELECTR�C Q �_'� (1FIISSECIIONNE�NOTBEODMRt�EDOFIHEPEflhYfVSFORONEM11�DfiED�OLlARS(EfO�ORLES3} PLUMBING '"" � "' '�':'� � , C Z� I CERTIFYTHAT INTNE PEHFOHMANCE OF THE WORK FOR WHICH THIS PEFlAIT IS ISSIIED,l MECHANICAL _ ' Cj, SHALINDTEMPLOYANYPER50NINANYMANNEfi50ASTOBECOMESUBJECTTOTHE � �` WORKEHS'COMPENS/TIONUWSOFCAL�FORNIA,ANOAGREETMATIFISHWLDBECAME INSPECTIONFEE +I � SUBJECTTOTHEWOfiKERS'CAMPENSATIONPROVISIONSOFSECTION31000FTHELABOR � � �, CADE,ISMALLFOfiTHWITHCOMPLVWI7HTHO5EPflOVISIONS. �SSUANCE ��"�'g� 'g[j� � � SMIP ."t -8+�..e 46 (.' i�YJ' y -•�tp. 'UATE: APPLIGANT. __ � � w ENERGY P/C J- WARNINO:fAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNUIWFUL,PNDSHALLBE �y,,. SU&IECTANEMPLOYER70CAIMINALPENALTIESANDCIVILFINESUP700NEHUNDflED7H045AN� ENERGYPERMIT OIX.LAflS(5100,Oao�IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN - J�� BECTION37oBOFTHELABORCODE,�NTERE57,ANDATfOflNEY'SFEES. RETENTIONFEE: 2; �?: CONSTRUCTION LENDING AGENCY PRE-ALT FEE: Ot � IHEREBVAFFIRMUNOERPENALNOFPERIURYlHATTHEREISACANSTRUCTIONLENDINGAGENCY �� FOR TME PERFORMMICE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED(SEC.30W,CIV.C.j. -- Zi W' � �1 LENUER'S NAME_ � F'� LEN�ER'SA�OHESS --. w I CERTIfV�N4T i HAVE READ THIS APPLICATION AND STATE THATTNE PBOVE MFORMATION IS GORRECT. TOTAL FEES � IAGREETOCOMPLYWITHALLCITYANDCOUN7YORDINANCESANDSTATELAWSRELATINGTOBUILOING � CONSTpUCTION,ANO NER�BV AUhDHIZE REVNESENTATIVES DF TNIS CDUNTY TO ENTEH UPON TME Z AB,O/Y�E•MENTIONEOPROPERiYFORINSPECT PURaoses. 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