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HomeMy WebLinkAbout16001 __ _ ___.__ , , _ _ ������� . , CITY OF DIAMOND BAR ���,��.,� --��� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � w 21660 E.Copley Drive Suite 190 ���cC/ (909)860-3195 Fac(909)8b1-3117 PRESS ����9M°� BUII.DING PERMIT APPLICATION FIRMLY JOBSITE APPLICATION PERMIT P!C . a ADDRESS � DA7E � /�6I O� NUMBER 16001 q � ISSUE TYPE OCC -- APN LOT TRACT DATE CONST. GROUP °C OWNER O " AD S . Y �1~ ZONING SETBACKS � CI� TEL FRONT RW ❑ APPUCANT TEL. . REAR ❑ � SIOE/SICE STREET RW ❑ CONTRAC�, % SIDE ❑ g ADD S� PROPOSED USE o CI I EL. �+ ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� ' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECI.ARATION SFR/ADD/REM O 1 HEREBV AFFIRM UNDEF PEN,LLTY OF PERIURV THAT I M1 EXEMPY FROM THE CONTRACTORS LI� G3f1J8IC2fpOh W CEN9EUWFORTHEFOLLOWINOREA90N(SEC.7o97.5BUSINES9ANDPROFESS10N9CODE:ANYCITVOR (fj � COUNT'/WNICMflEWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W pgtl0/DBCIC NRE,VflIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICqNT FOR SUCH PERMIT TO FILE A SIGNEO SUTEMENT THAT HE OR SHE IS LICENSED WiiSUANT TO THE PROVISIONS OF THE CONTRACTORS L4 � CENSE LAW I��ER 91�MENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AN�PRO� � POOVSpd FESSqNS COOE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP� TqN.ANVV101.ATIONOFSECTION7031.6BVANYMPLICANTFOFAPENMITSU&IECTSTHEAPPLICANTTO Z Ra-Roof � ACIVIL PENALTV OF NOT MDRE THN1 FIVE HUNDRE�DOLUIRS(f5o0).�: � ❑I.IISONRJEROFTNEPPOPERTY,OPMVEMPLOVEESWITHWAGES0.5THEIRSOLECOMPENSATION, � Commercial - VALL DO THE WOpK,AND 7HE STFUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(&EC.7a�,BUSI- J � NESS AND PHOFESSIONS COUE:THE CONTMCTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF ? PROPERN WF10 BURA4 OR MAPROYES hIEFEON,AND WHO DOES SUCH WORK HIMSELF OR NEFSELF OR � TNROUGHHISORHEROWNEMPLOVEES,PROVIDEDTMATSt/CHIMPROVEMENTSARENOTINTENDEDOfl m OOFFEREDFORSQEIF,HOWEVEi�iHEBUILDIN00RIMPROVEMENTI550LDWITr7INONEVEAROFCOMPLE- Z TpN,THE OWNER�BULLDER NALL HAVE THE BURDEN OF PROVING THAT HE OH SNE DID NOT BUIID OR = IMPROVEFOHTHEPIIRPOSEOFSN.E1. W ❑I.ASOWNEROFTHEPROPERTV,AMEXCLUSNEIYCONTRACTINGWRHLICENSEDCONTqAC70p5 � TD CONSTRUCT THE PRQIECT(SEC.704/,BUSINE55 ANO PROFESSIONS COOF�hiF CONTRACTORS LI- V8IU311011 ADJ.AREA W CENSEUWDOESNOTAPPIYTOMIOWNEROFAPpOPERiVWHOBUILpSORIMPROVESTHEREON,ANO � YhIOCONTRACTSFOiiSUCHPH0.IECTSWITHACONTMCTOR�S)LICENSEDPURSUANTTOiHECONTRAC- QUANTITY DESCRIPTION FEE Y TORS UCENSE UW.�. � ❑I M/EXEMPTUNDER SEC. 8.6 P.C.FOF 7HI5 REASON Q 3 �' � � DATE _ OWNER U � W LICENSED CONTRACTORS DECLARATION � � w 1 HEREBV AFFIRAI UNDER PENALTY OF PERJVRY TNAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � � B(COMMENCINq WITH SECTION 7C00)OF DIVISION 3 OF THE BUSWESS AND PROFESSIONS CADE,ANO Z ?G� MV LICEN3E IS W FUL R�D EFFECL � llJ 0 UCENSE L45 � LIQ NO �' � � J V DATE CONi � � W � WORKERS'COMPENSATION DECLARATION -� ¢ � 1 NERFBY AFFIRM UNDER PENALTY OF PERJUFY ONE OF THE FOLLOWING DECIARATIONS: Z 0 _IHAVEANDWILLMANTAINACERTIFlCATEOFCANSEN7TDSELfdNSUREFpRWOFKEFS' _ COMPENSATION,AS PPOVIOED 8V SECTION 37000F THE LABOR CODE.FOR THE PERFORMANCE `U F 7HE WORIC FOR WHICH THIS PERMIT IS ISSUEO. � O � IHPVEANDWILLMAiNTA1NWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBVSECTqN Q37000FTHE RCOOE,FORTHEPERFO@MANCEOFTHEWORKFORWHICHTHISPERMITIS � ISSIJE�.�EA CO PENSATIONINSI�ANCECA ERANDPOL 9ERARE: CONSTRUCTION 1 � CARRI, � !� � PIAN REVIEW Z POLICYNUMB ��— - �ll Y EI.ECTRIC Q � (iTil$SECiqNNE�NO70E00MRETEDOFi7fcPEAMfi'ISFORONEHUWRE�OOItfJU(E140)ORLESS�. PLUMBING � Z I CERTIfV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAI _ _ (�S SHALLN�T EMPLOV ANY PEfiSON IN ANY MANNER SOAS TO BECAME SUBJECTTO THE '+ +� �• a""q 5 � WORKER5 COMPENSATION LAWS OF CALIPoF AND AGREE THAT IF I SHOl1Lp BECAME INSPECTION FEE f A�.itl P ��-'� ,��I i SUBJECT TO THE WORKERS'COMPENSATION VISIONS OF SECTION 310o OG THE LABOR Q 5 DE, 5 ALl i'ORT I COMPLV WI OVISIONS ISSUANCE ^�[' 'y"�'�� 'p�f ���� -� �.u O DATE: LICANT. � SMIP S114 Z 6J7i�,'(A^""- y TC7 wWARNING FAILURE TO SECURE WbRKEflS'COMPENSATION COVERAGE IS UNUWFUL.AN�SHALL BE ENERGY PJC �{�J�.Dll�� }'��� $ � SUOJECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHUN�REDlHOl15AN� ENERGYPERMIT DOI.U�RS�f 100,0001.�N ADDITION TO 7HE COST OF COMPENS0.TIIXJ,DAMAGES AS PROVIDED FOR IN ¢ SECTION37oBOFTHELABORCOOE,MTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: nW. CONSTRUCTION LENDING AGENCY PRE-AL7 FEE: O � IHEREBVAFFIRMUNDERPENALTVOFPERJURVTHATTNEREISACONSTRUCTIONLEN�INGAGENCY _ FOR THE PERFORIAANCE OF THE WORK FOR WHICH THIS PEqMIT IS ISSl1E�(SEC.309],CIV.C.). . Z W � LENDER'SNAME F-- LENDER'SAD�HESS � ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEA60VEINFORMATIONISCOflRECT. TOTAL FEES W I AGREE TO CAMPLV WITH ALL CITY RNO COUNTV ORDINANCES Ml0 STATE IAWS RELATING TO fiU1LDING � CONSTRUCTION,AImNEFE8YAU7H I REPRESENTATIVESOFT SCOUNTVTOENTEflUGONTHE Z -MENT EDP CERTYFOR SP rioNr�aaos . COMMENTS � ' r y / CU EE (p� Cn �. � '/ � G M E E = RECPT,NO. 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