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HomeMy WebLinkAbout11438 f�r t 1 i - CITY OF DIAMUND BAR � '�� �'* �� COMMUNITY DT'VELOPM�NT DEPARTMI3NT ��� ` �iR � _,,,�• . 2f(GO E.Coplcy Drive Suite 190 � PRESS � (909)8G031J5 Pax(909)R61-3117 """,'.� � BUILUING PLRMITAPPLiCATION FIRMLY j } JOBSITE ,' J �. APPLICATION `f ��1 PERMIT P/ ��� ¢ ADDRESS � �� �` �'`�C�s^ r��� � DATE ,� I NUMBER��� #_ v I � � ISSUE TYPE ' OCC I � APN LOT____,____ TRACT DATE_����� CONST. _ GROUP � p OWNER I.�t%�1t� (G I'�_ ZONING SETBACKS W AD�RESS_j.��� e+�'��r'm 7 �.g__ �r;� - FRONT RW U � Z CITY_�4_� ZIP�,�-� TEL. (�� �f�°.. � ----- - REAR �-1 � 0 APPLICANT �Lr.�.LJ'�'�2- _ TEL.___ SIDE/SIDESTREET____.____.___,____ RW_ iJ.__._.._..__- � m SIDE � _ i� � CONTRACTOR_.________- __._... _ � ADDRESS--- --.--.-- ������' ( --- PROPOSED USE---- -----�-------�----�- - _ _ — � � CI7Y_ ZIP TEL.___ J w ARCH/ENG/ �� i z DESIGNER h"�'���''_ NO.DWEL. NO. 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FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION �� SFR/ADD/FEM � O • � '� I 1{[f1f:RY AFFIRM UNDER PENALTY OF PLRJUHV THAT I AM EXEMPT FROM THE COIVTRAGTOHS LI� � Garage/Carport W CENSELAYlFOH'l1iE�OLLOWINGREASON�SEC.7031aBUWINESSANUPROFFSSIONSCODE.ANYCINOR � CJ WUNTYWHICHREOUlflESAPEFA9ITTOCONSTAUGf,ALTCR,IMPROVE,DEMOI.IFH,ORflEPAIfiANYSTRUC- w patio/�eck i � TIIRE,PNI�R TO Ifc ISSIIANCE,AL50 REOUIRES 1HE APPI ICANT FOR SUCH PERMITTO FlLE P SIGNE[) STATEMENT THAY HE OR SHF.IS LICFNSEO PURSUANT TO 1HE pROVISIONS Of TH[CA4TRACTOflS LI� � Cf.NSE LAYI(CHAPTER 9(COMMENqNG WITt1 SECTIOY]000)OFDIVISION30F T�I[BUSWESSAND Pq0- LL' Pool/Spa { O; FESSIONSCO�E)ORTIIATHEORSHEISEXEMPTTHEHEFROMANfJTHE8A515�OfiTHEALLEGEDEXEMP� (� TION.ANYVIOLATiONOf-SECTION7oat.5AVANVAPPLICANTFORAPERMITSUfiJLCTSTHLAPVUCANTTO z Re-Foof '� � A CIVIL P[NAL'fY OF NOT MORE THAN FIVE HUNOREU[70LLARS(85oa).�: 0 ❑I,ASOWNEROFTH�pROPERTY,ORMYEMPLOVEESWITHWAGE5F5THfIft50L[CAMf'CNSATI04, � Commercial � Z WILL 00 TH[WORH,AN�THe STHUCTUflE IS NOT INTCNDFD Ofi OFFEflED FOH SALE(SEC 70A4,I3USI� J NESS AND PqOFE5510N5 CODE:THE CONTRACTORS UCENSE LnW�OES NOT APPLV TO AN OWNER OF � N PflOPCHTYWHOBUILD50flIMPROVLSTM[FiEON,ANDWHODOE55UGHWORK411MSELfORH[RSELFOfl m � � TkIHOUG41HI50Rf1EHOWNEMALOYEES,PHOVIDECTHA'fSUCHIMPROVEMENTSARENOTINTENUEDOR ,1 ,Q OFFEREDFORSALE.IF,HOWEVf:RTHEBUIIDINGORIMPHUV[Mf:NTISSOLf7WITHINO4EVEAROFCOMPLE- � Z T:ON.TI1L OYlNFft BUI.DER WILL fi�VF THF�URDEN OF PROVINCi THAT Nf.OFl SHF DID NOT PUII.D Ofl ^}^�_ � IMPROVFi FOH THE PUHPOSE OF SAIE). � L� ��"� ] 'l I,AS OWNEF OF Tli[71i01'EFlTV.AM EXCLUSIVEIY CONTRACTING WITH LICENSED CANTRACTORS y a .� TO CONSfflUCT THE PROJECT(SEC.7040,BUSINESS AND PROFESSIONS CODE.TIIE CONTRACTORS LI- dlllatlOn ____ ADJ.AREA__,_.__.____,,,__ W CENSEL0.W�0[SNOTAPPLYTOANOWNEROFAPf1OPfRTYWHOBUILDSORIMPROVESri�EflEON,AND � �� WHOCQNTRACTSFORSUCHPR0.IEC�SWITHACONTRACTOR(S)LICENSFDPURSUANT'fOiHECANTRAP QUANTITY DESCRIPTION FEE 3 lOitS f.ICE�SE I.ANJ.J. Y � O J t:l l AM[XEMPT UN�ER SEC.,._, 8.A P.0 FOR THIS REASON Q � U ---"-- -... .. .- � � � UATF��_ OWNER � t�.. _"__._.�...v � U � �.._.... � W � .� LICENSED CONTRACT RS DFCL RATION . W � � IHf:REDYA�FIPMUNDERPEN.4LTYOFPLFiJURYTHATIAMLICENSEDUNUtRPROVI510NSOFCHAPTER � � 0(COMMENCINGK'ITHSECTION7000)OFDIVISION30FTHCf3USIN[SSANDPROFESS;ONSCODF.AND z X MV LICEYSE IS IN FUII FOHC[AND EFFCL`T m v W � � ,� LICENSG C�ASS_.._.,. __LIQ NO... _. _..___.. J � �U' CONTRACTON___"________ � a DAT[._._.- ._....'__' � W j �� WORKERS'COMPENSATION DECLARATION Q � � U ;� I HEREBYAFf�IRM t1NDER PENALTY OF PEFlJUHY O�E OFTHE FOLLOWING�ECLAllATIONS: Z j .O __. IHAV[ANUWII.LMAINTAINACER11fICAf[()�CONSENTTOSELF�INSUHE�OFiWOHKf:RS' y � Z COMPENSATION,ASPf10VIDEDBYSECTION37f190FTHELABORCODE,FOHTHEPEFlFOF7MANCE W ¢ OFTH[WORKFO(1WHICHTHISPfRMITISISSUGD. �, � j W IHAVEANUWILIMAINTAINWOFKERS'COMPC-NSATIONINSIJRANCE,A5RE0UIREDOY$C:CTION Q 3700 OF THE LA6�R CO[7E,FOR THE PERFORMPIJCE Of THL WORK FOR WHICH THIS PERMIi IS �� �F� '� ISSUEO.MV WOHKEFlS'CQ4IPCNSATION INSURANC[CAHHIER AND POLICY NUMBEFAFE: f �� a __' '— � � cnRHiEn --- - - --- � ---- - PLAN REVIEW 1 ".� � ...------- '� POLICY NUMOER ..._-.... ..- .--�— ELECTRIC __ Z ,¢, �0 (1}ASSECTNXJNEFDNOTBEOOMPLET[DOFTHCPERMfTISFORONEHUt�URFDDOIWiSB100)ORLESS) PLUMB�NG ...... --'-'----'- ,W.. Z' I CERTIFY THAT IN THf PERFORMANCE OF TI IE WORK FOR WHICH THIS PEHMIT IS ISSU[D,I M --------- -- i 7:�']� SHALL NOT EMPIOY ANY PERSON IN ANY MANN[R SOAS TO B[COME SUBJECTTO fHE -- --- ___--- „�� WOHi(EPS'COMPC-NSATIONLAWSOfCALIfORN1A,ANDAGREET{iAilflSflOULbRF.COME INSPECTIONFEE ,F SUBJECTTOTHEWORKFf1S'COMPENSATIONFfiOVISION50FSECT10�37000FTHf:LA[ibR � G, � I ,O„ CODE,ISHALLFORTIiWITHCOMPLVWITIITHOSLPROVISiONS. , 'p' DATE:_.._ __ APPLICANT: A SMIP ,_ P I ,J --------'- �---- ENERGY P/C (�� � ----...----- �J WAiiNING:FAILURE TO SECURG WOI1K[flS'COMPENSATION COVERAG[IS UNLAWFUL.AND SNAI.L 6F: � 'LL SU&IECTANEMPIOYF:kiTUCflIMINALPEN�LTI[SANDC:VILFINESUPTOONEHl1NDRfDiHOl1SAND ENERGYPERMIT -. _ `` .----_.�_ DOLLAfiS(S1W.000).IN ADDITION TOTHE COST OF COMPENSATION,DAMAOES AS PROVIUED fOfi IN � M��, SECTION 3708 OF THE LABOR CADE,INTEREST.AN�ATTOfSNEY'S FEES. RETENTION FEE: s•� "W CONSTRUCTION LENDING AGENCY PRE-AlT FEE: �,� %O r'� , I Q. IHEREBYAFfIHMUNDERPENALTYOFP[HJUFYTHATTHERE�SACONSiHUCTIOYLENDINGAGENCY _ ____,____.,. ��'• ____ � n- FORT4IE PfiRL'OfiMA�CE OF THE WOf7K FOR WHICH THIS PEflMIT IS ISSU[D ISEC.3097,CIV.CJ. ' Z� ' _'—_'' —' W, ��_`� LENDEfI'SNAME _"'_"' ' _'__" .. _.._. __.. ,�_ '_'-_—_- -_" F-:� fEN�[R'SRODRE55..__.,_._ ..-_ - -----�- - ,�:w. ICERTIFYTHATIHAV[REA�THISAPPLIGATIONPNDSTATETHATi'l1EABOVEINFORMATIONISCORRECT. TOTALFEES S � �, IAGHEETOCOMPLYWITNALLCITYANDCOl1NTYOR�INANCESANDSTATElAWSRELA�IfvC:TOl3U11�ING /J� CqNSTRUCTION,ANDHEREBYAUfHOH17.f.REPIlESENTATIVE50FTHI5C9UNTVTOENTEqUPONTHE � ��� �"! A(30VE�MENTIONED PROPEHTY FOfI INSPECTION PURPOSES. C�� :�Z:� . COMMENTS__. � ��� �!V �� ��� ---- ' ---- - -- ------ ;,�' ' _...--- - ? m :fiMITTEE NA -.. 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