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HomeMy WebLinkAbout17242 (23) — - �—__ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNTI'Y 8c DEVELOPIvIENT SERVICES �_� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS �`-�r*��' BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE �-''� j / APPLICATION PERMIT P/C Q ADDRESS����� C%�C'�G` P�'S h ��h __ pATE �Q—/Z 'Z��''I NUMBER�� # m ISSUE V TYPE OCC APN LOT TRACT _ DATE ��! ���� � �� G CONST. GROUP p OWNER l c 4�^ f� " ADDR S ' s-?-� Ccid/t/�!'�(i5 r ZONING SETBACKS Z CITY �t y✓hC�,�v,�o' �G�� ZIP / / TEL.q 111 TG�'-9 Z FRONT RW ❑ Q APPLICANT �f�w ,��,..f iyr t TE �� �c+-S4Vs y REAR ❑ � SIDElSIDE STREET RW ❑ � CONTRACTOR_ SIDE ❑ O ADDRESS � PROPOSEDUSE �L'I�Ca� " �'Cp►G�o�' ��� �yesax.{�,[�ijq' 'a Q CITY ZIP TEL. �,,7�/ p,�r� �w-/,�� �DaA+�r� ?�vn w ARCH/ENG/ y � z DESIGNER NO.DWEL. --' ! 1N0. NO. w � ADDRESS UNITS � STORIES BEDROOMS � CITY ZIP TEL. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDJREM O C] I HEREBY AFFIRM UNOER PENALTY OF PEFJURV THAT I AM E%EMPT FROM THE CON7RACTORS LI� � Garage/Carport W CENSEUIWFORTNEFOLLOWINGREASON(SEC.7D31.SBUSINESSANOPROFESSIONSCODE:ANVCITVOR U COUNTYWHICHRE�UIRESAPERMfTTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORflEPAIRANYSTRUC- W Patio/Deck Z TURE,PFIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICAN7 FOp SUCH PEPMIT TO FILE A SIGNE� w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFOVISIONS OF THE CONTRACTORS Li� W � CENSE LAW(CHAPTER e(COMMENCING WITH SECTION J000)DF DIV�SION 3 Oi THE BUSMESS AN�PRO� V' POOUSpe � FESSIONSCO�E)ORiHATHEORSHE�SEXEMPTTHEREFROMANDTHE9ASISFOftTH[ALlEOEDEXEMP� � ^ V TION.ANYVIOLATKKJOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z RB-RODf ��UV AqVI PENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS(E500).): � �ASONRJEftOFTHEPROPERTY,ORMVEMPLOYEESWITHWAGE5A5THEIR50LECOMPENSATION, 0 Commercial � WILL THE WORK,AND THE STRUCTURE IS NOT INTENDEO OR OFFERED FOR SALE(SEC.704�,BU51� J � NE55 AND PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW�OES NOT APPLV TO AN OWNER OF � PROPERTV WHO BUILDS OR IMPROVES THEREON,AN�YUHO DOES SUCH WOHK HIMSELF OR HERSELF OR d THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPFOVEMENTSARENOTINTENOEOOR m OOFFEREOWRSILLE.IF,HOWEVER,THEBUIL�MGORIMPROVEMENrI55q.�WITHINONEYEAROfCOMPLE- Z T�ON,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVMG THAT HE OR SNE OID NOT BUIL�OR � IMPROYEFORTHEPURPOSEOFSALE). w ❑I,ASOWNEROFTHEPROPERTY,AME%C'_�SIVELYCONTFACTINGWITHLICENSEDCONTRACTOHS _ /yq�.�y��'g [[ TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CO�E,THE CONTRACTORS Li� Valuation G:+'�-•"(...! ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHDBU!LOSORIMPR�VESTHEREON,AND � WHOCONTRACTSFORSUCHPROJEC7SWITHACANTRACTOR(S�UCENSEOPUqSUANTTOTHECONTRAC� OUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). � ❑I AM EXEMPT UNDER SEC. B.8 F.G FOFi THIS REASON J O '¢ � U � ,DATE��'�/��Z{�r � NE{7 U W � LICENSED CONTRACTORS DECLARAT ON w ¢ CL IHEHEBYAFFIRMUNDERPENALTYOFPERJURYTH0.TIAMUCENSEDUNOEAPROVISIONSOFCHAPTER � p� e(COMMENCINGWITHSECTION70o0JOFDIVISiON30FTHEBUSINESSANDPROFESSIONSCODE.ANO Z `X MY LICENSE IS IN FULL fORCE AND EFFECT. m ' � LICENSE CLASS IIC.NO. � � J � � DATE CONTRACTOR �- � W � WORKERS'COMPENSATION DECLARATION � Q � U � IHEREBYAFFlRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIDNS: Z Q z __I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF-INSURE FOR WORKERS' 2 Q CAMPENSATION,AS PPOVI�ED BY SECTION 3']Do OF THE LABOR CODE,FOR THE PERFORMAYCE �U OF THE WORK FOF WHICH THIS PERMIT IS ISSUEO. � � � _IHAVEANOWIL4MAINTAINWORKERS'COMPENSATIDNINSl1RANCE,ASREOUIRE06V5ECTION f y�-� Q 3�o00FTHELA90RCO0E,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEfiMITIS f /"'��,`l ( ] Q ISSUE�.MV WORNERS'COMPENSATION INSUFANCE CpRRiERANO POLICV NUAABEAARE: CONSTRUCTION ! �I l/ J j caRR��ER PLAN REVIEW Z POUCYNUMBEA ELECTRIC ¢ (IHISSECTKKJNFIDNOTBEOJMPL.EfE00FiHEPERMf"LSFORONEHUPDREDOOlLARS(E10J)ORLESS} PLUMBING � Z ICERTIFV7HATINiHEPEFFORMANCEOFTHEWORKFOFWHICHTHISPERMITI5155UE�.l MECNANICAL (� SHALL NOT EMPLOY ANY fER50N IN PNV MANNER SO AS TO BECAME SUB.IECTTO THE Uj WOFlKERS'COMPENSATIONLAWSOFCAUFORNIA,ANDAGREETMATIFISHOULDBECOME INSPECTIONFEE = SUBJECTTOTHEWORKERS'COMPENSATIO�PROVISIONSOFSEC'ION37000F'HELABOfl ` GOOE.I SHqLL FORTHWITM COMPLV WITH THOSE PROVISIONS. ISSUANCE � SMIP ' � �� p DATE: APPLICANT. � WARNING F0.ILURE TO SECURE WORKEPS'COMPENSATION COVERAGE IS UNUIWFVI,AND SHALL BE ENERGY P/C � SUBJECTANEMPLOYERTOCRIMINALPENAITIESAN�CIVILFlNESUPTO04EHUNOREDTHOUSAND ENERGYPERMIT OOLLARS(Ei a0.000),IN ADDITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIDED FOR IN � SECTION 370B OFTHE 1A80R CODE,INTEREST,AN�ATTORNEY'S FEES. RETENTION FEE: � " � n�,. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREB�AFFIRM UNDEP PENALTV OF PERJURY THAi THERE IS A CONSTRUCTION LENOING AGENCY FOR THE PERFORMANGE OF iHE WORK FOR W HICH THIS PERMIT IS ISSl1ED(SEC.3097,CIV.C.). Z W � LEN�ER'S NAME F— LEN�ER'SAD�RESS � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �^��'� � t,/' w I AGREE TO COMPLV w17H ALL CITV pN0 COUNTY ORDINANCES ANO STATE LAWS RELA"ING TO BUILOING � CONSTFUCTION,ANDHEFEBYAUTHORIZEREPRESENTATIVESOFTNISCOUNTYTDENTERUPONTHE Z A60VE�MENTIONED PROPERTV FOF INSPECTICN PURPOSES. COMMENTS � ��c6�a X,r�e>�a zrA���,u� r _ m PERMI7'fEENFM �PFINT) � `�1'G:�-. .�� !0 �-l2-Z��o J � SIGNATU OFPERMITTEE DATE —y RECPT.NO. 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