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HomeMy WebLinkAbout17061 CITY OF DIAMOND BAR . � -�`� -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � a. w l ., 21825 E.Copley Drive �� (909)860-3195 Fax(909)861-3117 PRESS �"������ BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE ��� �t /^ � � b ����� # � APPLICATION PERMIT p/C o ADDRESS_ � �^.��� �s� DATE NUMBER �° APN LOT TRACT_ D TE � NPE OCC p OWNER At�N-t1 �'✓tv� CONST. GROUP p ADDRESS � ZONING SETBACKS FRONT z CITY ZIP TEL. •- I RW ❑ � APPIICANT TEL. REAR ❑ z SIDElSIDE STREET RW ❑ ¢ CONTRACTOR �i'�. C K _ i�n�__�_�N C . SIDE � Q ADDRES Mu. �� as � CITY v� • ZIP �� TEL.���-34�`a.S� PROPOSE_§�,USE �� v� � f � C�' G.4 o ARCH/ENG/ !�a�� w �"k @ z DESIGNER v� t""'� � • 3cv.n sF w NO.DWEL. NO.. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFlRM UN�ER PENALTV OF PERJURY THA71 AM EXEMPT FROM THE CON7RACTORS LI� Gdfd9e/Cefpolt W CENSEIAWFOR'HEFOLLOWINGREASON(SEC.7031.58USINESSAN�PROFESSIOPISCODEnNVCITVOP (n U COUNTYWHICHREOUIRESAPEiiMIiTOCONSTRUCT.ALTER,IMPROVE.�EA�OLISH,OPREPAIRANVSTRUC� W Patio/Deck W TURE,7RIOR TO ITS ISSUANCE,ALSO REOIJIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W � STATEMENT THAT HE OR SHE IS LICENSED PURSUAM TO THE PROVISIONS OF THE COMRACTORS LI� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION)000�OF DIVISION 3 OF THE BUSINESS AND PRO� LL POOVSPB Q FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROM/1NOTHEBASISFORTFIEALLEGEDE%EMP� � V TION.ANYVIOLATIONOFSECTION7o31.5BYANYAPP�ICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACIVIL FENALTY OF NOT MORE THAN FNE HUN�REO OOLLARS(SSDO).): � ❑I,ASOWNEROFTHEPflOPERTY,ORMYEMPLOVEESWITHWAGESASTHE1RSOlECOMPENSATION, ❑ COfI'If118fC19I Z WIIL DO THE WORK,ANO THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SECJ044,BU51- J � NESS AND PROFESSIONS CODE THE CONTRACTORS UCENSE LAW DOES NOT APPLV 70 AN OWNER oF � PROPERTY WHO BUIL�S OR IMPROVESTHEREON,AND WHO�OES SUCH WORK HIMSELFOF HERSELFOR fL TNROl1GHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q OFFEREDFORSALE.IF,HOWEVER,THEBVILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- Z TION,THE OWNER-BUIIDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD Oft = IMPROVEFORTHEPURPOSEOFSALE). w ❑I,AS ON7JER OF THE PROPEFN,AM EXCLUSNELY CQNTRACTING WITH LICENSED CONTRACTORS � TO CONSTRUC7 7HE PROJECT(SEC.7044,BUSINESS AN�PROFESSIONS COCE'.THE CONTRACTORS LI- ValU8ti0n ADJ.AREA W CENSELAWDOESNOTqPPLYTOANOWNEFOFAPROPERNWHOBUiLD50RIMPROVESTHEREON.AND � WHOCONTRAC7SFORSUCHPROJECTSWITHACONTRRCTOR(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). � ❑I AM EXEMPT UNOER SEC. B.8 P.C.FOR THIS REASON Q ?� U tL ¢ DATE OWNER F- O w � LICENSED CONTRACTORS DECLARATION W ¢ CC I HEREBYAFFIRM UNDER PENALTV OF PERJURY THA71 AM LICENSED UNDEF PROVISIONS OF CHAPTER � � 9(COMMENCWG WRH SEC710N 7000�OF DIVISION 3 OF THE BUSINESSAND PROFESSIONS CODE,AN� Z X MY LICENSE IS IN FULL FORCE AND EFFECT. � LIGENSECLASS ` '�� LIC.NQ �� / S!7� � V �ATE ��fl I CONTRACTOR �,� _- � a W � WORKERS'COMPENSATIO ARATION ¢ � IHEREBVAFFIRMUN�ERPENALNOFPERJURVONEOFTHEFOLIOWIUGOECLARATIONS: Z � _I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEIF-INSURE FOF WORKEPS' a S Q WMPENSATION,ASPROVIOEDBVSECTION97000FTHELABORCO�E,FORTHEPERFORMANCE U OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. W � � Qw _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION (� s� J� 3"/OO OF THE LABOR CODE,FOR THE PERFORMANCE OF TNE VJORH FOq WHICH THIS PERMIT 15 X�y / ,( � ISSUEO.MY WORKEFS' PENS TION I�IS�RANCE CA IER AND PDUCY NUMBER ARE: CONSTRUCTION C..> L/`� Q ` � CARRIER Ao4A (/�^� °^ __ ______ PLAN REVIEW � POLICYNUMBER I/'L '.?C�4_if r'� � ELECTRIC ¢ t�/�'J i�('i � (fHISSECTKKJNE�NOT8E00MPLEfEDOFTHEPE{MMISf-0RONEHUNDHE�L1�lI.AR:�§f0�)OFiLESS). PLUMBING Z ICERTIFYTHATINTHEPERFORMANCEOFTHE ' WHICHTHISPEflMiTI5155LJE�,I MECHANICAL '�} SHAIL NOT EMPLOY ANY PERSON IN AN ER SO AS ECOME SUBJECT TO THE � WORKERS'COMPENSA710NLAWSOF ALIFORN�A,ANDAGR THATIFISHW COME INSPECTIONFEE = SUBJECT70 THE WORKERS'COMPEN..TION PROVISION F SECTION 37 F THE LAB F ^L r,.�� CODE,I SHALL FOR HWITH COMPLY WIT OSE PR ioNs. �SSUANCE �"j Gt.J O � SMIP Q p �ATE:�_� APPLICANP, - J WARNING.FAILURETOSECUREWOFtKERS'COMPENSATI COVERAGEI WFUL,ANDSHALLBE ENERGYP/C � SUBJECTANEMPLOVEHTOCRIMINALPENALTIES ILFINESUP700NEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS15700,000),INADDITIONTOT COMPENSATION,�AMAGESASPROViOEDFORIN J SECTION37aBOFTHELABORCODE,W7EREST,ANOATfORNEV'SFEES , Q�y � RETENTION FEE: �l OCONSTRUCTION LENDiNG AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDMGAGENCY FOFTHE PERF-0RMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3057,CIV.C.�. Z W � LENDER'S NAME H LENDER'SAD�RESS � TOTAL FEES I � , 7� � I CERTIFV THAT I HAVE fiEA�THIS APPLICATION AN�STATETHAT THE ABOVE INFORMATION IS CORRECT. w I AGREE 70 COMPLV WITH ALL CITY AND COUN7V ORDINANCES AND ST0.TE UWS RELATING 70 BUILOING � CONS ,ANOFEREBVAUTHORIZEREPRESEVTATIVESOFTHISCOUNTVTOENTERUPONTHE � AB E-MENTIO EO PROPERTV FOR INSP N PURPOSES. Z COMMENTS � - J * � �Y� m P EE F (PRIIJn ¢ ���� � Uj SIGNATVRE O RMI E OA'E _ - RECPT.�0. PAID BY . VALIDATION ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File C P pY. py, py, opy,GREEN—ApplicanYs Copy ISa;$��'�$:.�al.t.f2k{t'�`; �waa.,w:i���ir.a�:`.'.'w`bflSh."� . Y�.,`;+�i'e$.m".'y�"`�-,�.�-.�,.c•, ,� �,..>,-.:�-��.. �� .� . . .�w<rrr, �k,�..?"8�'rP<'° '{p�''t+"IrkrY�i-,.x",.r;,,..r�+o-:ro. v+.. �.��,:�- . .�x4c:,ht.�.l�vas;•�;;�t�_ „ . R`�`'- - �'9�+t`�r"k. &�. � "�y P � 3 .�' �.��� � ',���'� ���:��h��, � � N . ��::::. � �'� . .� . �.,n �;� €�, �. 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