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HomeMy WebLinkAbout16044 (22) . ,� , , c'�;l',�`�i''e� . 1�_ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ����U�„r" „ 21660 E.Copley Drive Suite 190 �/`'� PRESS . :w ,y,A�,. (909)860-3195 Fax(909)861-3117 . BUII.DING PERMIT APPLICATION �`"r FIRMLY __.. � JOBSITE " p APPLICATIQN �,�� ��� PERMIT �i\� P/C o ADDRESS `� �'� ��E� /ti'�5 ��' ' DATE NUMBER V # c� ISSUE TYPE OCC APN l0T TRACT DATE CONST. GROUP p OWNER �9.�v1CNC �i4�r�/fv�il ADDRESS ' �/� ��c�� S +�2- K.-ZS ZONING SETBACKS � CITY �+'�� ZIP � 7� S� EL.�ol-���'�l Z� FRONT RW ❑ APPLICAN TEL. REAR ❑ SIDElSIQE STREEf RW ❑ � SIDE ❑ CONTRACTOR � °� l�� ' ��C � ADDRESS�-����;����� '� `"� PROPOSED USE CITY Lsh- ZIP 9 ° �'L TEL.S'�d'S$L'ST�I o ARCH/ENG! �z DESIGNER NO.DWEL. NO. NO. a, ADDRESS UNITS STORIES BEDROOMS = CITY ZIP 7EL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DECLAFiATION $Fq/qDDlREM 0 1 HERE6Y AFFlRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRqCTORS LI- � Garage/Carport W CENSEUWfORTHEFOLLOWINOREA50N(SEC.7D37.58USINESSIWDPRqFES510NSCQ�E:ANVC1iYOR V COUNTlWHICHREWIRESAPEFMtTTOWNSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAiRANY57RUC- W pelio/D6Ck WTURE,PRIOR TO ITS ISSUANCE,ALSO PE�UIRES THE APPLICANT FOfi SUCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROYISIONS OF THE CONTRACTORS ll- � CENSE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION a OF THE Bl1SW ESS AND PRO- � POOVSpB FESSqNS COOE�OR THAT HE OR SHE IS EXEMPT THEREFROM AND 7HE BASIS FOH 7HE ALLEGE�E%EMP- TION.ANYVIOUTIONOFSECTION7031.6BVqNYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-Foot � ACML PENALT'OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): � ❑I,ASOWNEHOFTHEPflOPERTY.ORMYEMPLAYEESWITHWA6ESASTHEIR50LECOMPENSATION, G COIIIRIBlCIflI '- WILL 00 THE WORK,AND THE STRUC7URE IS NOT INiEN�ED OR OFFEREO FOR SALE(SEC.7044,BU51- J NESS M1D PROFESSIONS COOE:THE COMRACTORS LICENSE LAW�OES NOT APPIY To AN OWNER OF � 7HOPERTYYIHOBUILDSORIMPROVES7HEREON.AN�WHODOESSUCHWORKHIMSELFORHERSELFOq = � THROUGHNISORHERONMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMEMSARENOTINTENDEDOR m QOFFEREOFORSALEIF,HOWEVERTNEBUILOINOORIMPFOVEMENTISSOLDWffHINONEYEAROFCAMPLE- Z TION,7HE OWNER-BUILDER WILL HAVE THE BUPDEN OF PROVIN6 THAT HE OR SHE DID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SAI�. ❑I,A6 ONMER OF THE PROPEiiTY,AM ERCLUSIVELV CONTRACTINQ WITH UCENSED CONTRACTORS Q TO CONSTRUCTTHE PROJECT(SEC.70N,BUSINESSAND PROFESSIONS CO�E:THE CONTRACTORS LI- VeI11821p17 ADJ.AREA W CENSELAWDOESNOTAPPLY70ANOWNEAOFAPROPEflNWHOBWLDSORIMPROVE6THEREON,AND � WNOCONTR�GTSFORSUCHPROJECTSWITHACONTMG70R(5)UCENSEDPURSUANT70THECONTMF QUANTITY DESCRIPTION FEE Y 70RS LICENSE uw.). g ❑I AM EXFJ.4PT UNDER SEC. B.&PC.FOR THIS PEASON Q 3 — � � u' DATE OWNER U � LICENSED CONTRACTORS DECLARATION -� � w IHEREBYAFFIRMUNDERPENALTY9FPERJURYTHATIAMLICENSEDUN�ERPROVISIONSUFCHAPTER � ` p� e�GUMMENCINOWRH5ECT10N7000)OF�IYISION30FTHEBUSINESSAN�PROFESSIONSCOOE,AND Z 4 X MV IICENSE IS IN FULL FORCE AND EFFECT. m /��,� n� L "L_ _ � UCENSE CLASS M LIC.NO. ,!� �� J U DATE� d� _ CONTRACTOR�__. �- W � WdRKERS'COMPENSATION DECLARATION Q � I NEREBV AFFlRM UNDEfl PENALTY OF PERJURY ONE OF THE FolIOWING OECLARA71oNS: U � Z Q L7 IHAVEANDWILLMAINTA�NACERTIFICATEOFCONSENTTOfiEIF-INSUflEFORWOFKERS' 2 � COMPENSATWN,AS PROVIDED 8V SECTION 370o OF THF.LABOR CODc,FOR 7HE PERFORM4NCE W OF THE WORK FOR WHlCM TMIS PEPMR IS IS5UE0. � Q W I HAVE AND WILL MAINYAIN WORI�RS'CAMPENSATION INSURANCE,AS RE�UIRED BY SECTION Q 3�0o OFTHE LA60R OOOE.FOR 1NE PERFORAAANC.F OF THE'JJORK FOfl WHICH THIS PERMITIS ISSUED.MV WORKERS'COMPENSAiION INSURANCE CARRIEF AND POIICV NUMBER APE: CONSTRUCTION � CARRIER �/�'Ka«� ��- PLAN REVIEW � POLICYNUMBER L✓�� p����� �� ELECTRIC � `� � �^ � (fFBfiSECtIqNNE�N0TBE0�MPLEfEDOF7HEPEFM5T6FOROME.F#FARE�OOLLAFU(57oo�ORLE55� PLUMBING �✓ C� �Qu � � I CERTIFYTHAT INTHE PERFOFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL � SHALL NOT EMCLOv ANY PERSON IN ANV MANNER SO AS TD BECOME SU6!ECTTO TNE �j WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGflEETHATIFISHOULDBECOME INSPECTIONFEE � SU&lECT70 THE WORKERS'COMPENSATWN PAOViSIONS Of SECTION 3'1Co OF TFiE LABOR CODE,ISHAL1�f-0RTHWITMCOMPLYWITHh10SE OVISIONS.�1��'�'" ISSUANCE � �/�,,�/� SMIP p DATE: �16-?{C7I APPLICANT: _ — J WAflNINO FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHAL.L BE ENFRGY PIC � SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN�CIVIL FlNES 11P TOONE HUNDRED THOUSAND ENERGY PERMIT OOUARS(51 aD,000).IN ADo1710N 70 THE COST OF COMPENSATION,�AMAOES AS PROVIDED FOR IN � SECTION37080FTHELABORCODE,INTEFEST,ANDATTORNEYSFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: - � ' � 1 HEREBYAFFIRM UNOER PENALTY OF PERJUiiY THAT Th1ERE IS A CONSTRUCTION LENDING AGENCY +.J�"�E Y �� �J , � FORTME VERFORMANCEOFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). ' ,z �.�`�����t r����'T-�,�� � LENOER'3 NAME -- ��1FY�77p7� b 7���C° , .y'��"�7 3A�_ �'y —"L:' 2A F= LENDER'S ADDHESS w 1 AGREE TO COMPLV W THAALL CITY PN�0 UNTY ORDINM'CES ANO STA�E LAWS REIAT NG TO BUIRDI� TOTAL FE ES �.,S� � CONSTRVGTION,AN9MENEBYAUTHORIZEREPRESENTATNESOFTriISCOUNTVTOENTERUPONTHE ' Z ABOVE-MEMIONED PROPERTV FOR INSPEGTION PURPOSES. COMMENTS �� _ �CC� JA�. l� _ . m PERMITT E NAME PRINT),6/!}�/ (n �^'�•`'y�� � �� C� ' � SIGNATl1REOFPEFiMITTEE DAT ' " = FiECPT.NO. 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