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HomeMy WebLinkAbout16933 � CITY OF DIAMOND BAR � — DEPARTMENT OF COIvII�fI1NTTY&DEVELOPMENT SERVICES 1 21825 E.Copley Drive '� (909)860-3195 Fax(909)861-311'l PR�SS "'%'�»���� BUILDING PERMIT APPLICATION FIRMLY ¢ ADDRIESS� �� D I � L DATEICATION �(��3"(�� NUMBER l� #C 0 9 o ISSUE TYPE OCC `^ APN--�,� LOT�—,,�y—` �TRACT DATE CONST. GROUP p OWNER !!''rUiC. N�lJf GlVD " ADDRESS ZONING SETBACKS Z CITY ZIP�� J TEL. FRONT RW O � APPLICANT TEL. REAR ❑ � SIDElSIQE STREET RW ❑ m CONTRACT R . . SIDE p oADDflESS � � � PROPOSED USE � _ CITY �� ZIP 1� - r2 TEL �Uv��TrP�� w ARCH/ENG/ ZDESIGNER Np.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � O OWNER-BUILDER DECLARATION SFFUADD/REM 0 1 HEREBV AFFIRM 11N�ER PENALTY OF PEFlJURV THAT I AM ExEMPT FROM iHE CONTRACTORS ll� G2fd90/CBfpOR W CENSELAWFORTHEFOLLOWINGREASON(SEC.7a31.5BUSINESSANDPROFES510NSCODE:ANYqTYOR (n U COUNTVWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC� W P8tI0I�BGIC Z TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT fOR SUCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSEO PURSl1ANT TO THE PROVISIO�S OF THE CONTRACTOFS LI� � CENSELAW(CHFPTER9(COMMENCINOWITHSECTION700a)OF�IYISION30FTHEBUSINESSANDPRO- � POOUSPB � FESSIONSCODEjORTHATHEORSHEISEXEMPTTHEREFROMAND?HEBASISFORTHEALLEGEDEXEMP- � TION.ANYVIOLATIONOFSEGTION7031.SBYANYAPPLICANTFORpPERMiTSUBJECTSiHEAPPLICANTTO Z Re-Root � ACIViLPENALTVOFNOTMORETHANFNEHUNDRED00LLApS(ESoo).)� 0 71,ASOWNEROFTHEPflOPERn',ORMYEMPLDYEESWITHWAGESASTHEIRSOIECOMPENSATION, 0 COfI1RIB1Cldl Z WILL DO THE WORK,AND TNE STRUCTURE IS NOT INTENDED OR OGFERED FOR SALE(SEC.�046,81151. J NESS ANO PROFESSIONS CODE:THE CONTRACTOflS LICETI5E LAW DOES NOT A7P�V TO AN OWNER OF � PROPERTVWH03UILDSORIMPROVESTHEREO��,ANDWHOOOESSUCHWOPKHIMS'cLFORHERSELFOF m � THROUGHHISORHEROWNEMPLOVEES,PROVI�EOTHATSUCHIMPflOVEMEMSARENOTWTENDEDOR W OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIAIPROVEMENTISSOLDWITH'NONEYEAROFCOMPLE 0 TION.THE OWNER�9VILDER WILL HAVE THE BUFDEN OF PROVING THAT HE OR SHE DI�NOT BUILD OR � IMPROYEFORTHEPURPOSEOFSALE). �yy CI,ASOWNEROFTHEPFOPERTV.AMEXCLUSNELVCONTRACTINGWITHLICFNSEDCONTRAGTORS Q TO CONSTRUCT THE PR0.IECT(SEC.7064,BUSINESS AND PROFESSIONS CODE:THE CONTRAC?ORS LI� V8IU2liOf1 ADJ.AREA W CENSEVIWDOESNOiAPPLYTOANOWNEROFAPROGERTVWHOBUILDSOHIMPROVE57NEREON,AND � WHOCANTRACTSFORSUCHPROJECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORS IICENSE IAW.�. � ❑IAM E%EMPT UNDER SEC. B.8 P.C.FORTHIS REASON U � � � DATE OWNEft_ V W � LICENSED CONTRACTORS DECLARATION W � I HEREBV AFFlRM UNOER PENALTV OF PERJUflY THAT I AM LICENSE�UNDER PROVISIONS OF CHAP�'ER � � 9(COMMENCINGWITHSECTION7000�OFDIVISION30FTFIE�USINESSAIvDPROFES510N5CODE,AND Z X MY LICENSE IS IN FULL FORCEA'J�EFFECT m LLf � � ����� � � UCENSE CLA „ LIC.NO. J V �A7E � CON7RACTOR, _ d W � WORKERS'COMPENSATION DECLARATION a � = U � I HEREBYAFFIPM UNOER PENALTV OF PERl11RV ONEOFTHE WLLOW�NG�ECl4RATIONS: � Z Q � �IHAVEANDW7LLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEPS' 2 COMPENSATION,ASPROVIDEDBVSECTION370aOFTHELA80RCO0E,FORTHEPERFORM0.NCE U � OFTHE WORK FOR WHICM iHIS PERMIT IS ISSUE�. � � W _IHAVEANDWILLMAIN7AINWORKEFiS'COMPENSATIONI4SURANCE,ASREQUIREDBYSECTION � Q 3�OOOFTHEIABORCOOE,FORTHEPERFORMANC_OFTHEWOPKFORWHICHTHISPERMRIS � ISSUED.MYWOR S' MP S N'NSU ANCECARRIERANDPOLICVNLIM9EFAHE: CONSTRUCTION � CARRIER �����_iyq/–� �/'/�;��--��-- PLAN REVIEW Z POLICYNUMBEF 1f ' `�� ELEC7RIC Q � � (MISSCCTIONNEmNO7BE00i�APLE7EDOFTNEPERAAffiSWRONEHU�WRE0DOL11�R.:(S1�a)ORLESSI. PLUMBING W MECHANICAL Z I CEPTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WH�CH THIS PERMIT IS ISSUED,I (J SHAILNOTEMPLOVA4YFERSONINANYMANNERSOASTOBECAMESU&IEGTTOTNE INSPECTIONFEE � � WOFKERS'GOMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME _, .. . . SU6JECT TO THE VJORKERS'COMPENSATION PROVISIDYS OF SECTION 37D0 OF THE LABOR �iy - 1= ISSUANCE ����-�./� � � � CO E, S L 7O�RTHWITHCOMPLVWITH7H ROVISIONS. ,.�—�–�—F-�.,u`.'� .� � r/ SMIP p DATE: � v APPLICANT /� J ENEFGVP/C 11f� '� �f1f11 � J WARNING:FA�LURE705ECUFlE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AN�SHALL BE �y Sl1&IECTANEMPLOYERTOGRIMINALPENALTIESANDCIYILFIN=SUPTOONEHUN�qEDTHOUS/1N0 ENERGYPERMIT DOLLARS(E100,000),IN ADD�iION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN . � SECTIONa7oeOFTHELABOHCOOE.MTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: ,..,�,.,y_. �� � w CONSTRUCTION LEND�NG AGENCY pRE-ALT FEE: �-��^- _.......�.:..�.._; a - - � INEFEBVAFFIRMUNDERPENALTYOFPERJURVTHATTHERE'SACONSTRUC710NLENDINGAGENCV FOR THE PEFFORMANCEOFTHE WOFK FOR WHICH 7MI5 FENMIT IS ISSUEO(SEC.3o97,CIV.C.j. Z W � LENDERSNAME k= LENDER'SAO�RESS /� / WICERTIFVTHA7IHAVEREADTHISAPPUCA710NANDSTATETHATTHEABOVEINFORMATIONISCOPRECT. TOT/'��FEES�{�//� � I AGPEE TO COMPLV WI7H ALL CITY AND CCUNTV ORDINANCES AND STATE LAWS RELAT;NG TO 9UILDING (}O W �� CONSTRIJCTION.AN�HEREBY AUTHORIZE REPRESENTATIVES OF THIS COU�TY TD ENTER UPON 7HE z ABOVE ENTIONED PROPERTV FOR�NSPECyION PURPO�ES. COMMENTS t � � b�r <��; = 3 m PERMI ME(P T) D/ Q � � SIGNATUR OFPERMITTEE OATE = RECPT.�O. PAID BY VALIDATION _ ~ WHITE—DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO File Copy,GREEN—Applicant's Copy ---�--__� �" .. . :�'.�. .. .� .:�,�. ��-y '..., ..w::::...- r� . :.,. ..._:�..��4 ,�l(2•,vtt` n1.X:_.�tl"_ T.��„FM i :' .. .c . .,i .. ..i. . �ro . . .. .,\.:4:y c ' . .. .. .. .....,1 ......_ .. .:.:., �. ,... ,.. �,..:-�. ,.y ,,.. . .. � , r �. � v. 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