HomeMy WebLinkAbout16778 (43) _____. -. __, --
`���� �5 �'� �.���
` �� CITY OF DIAMOND BAR �� e"'"�
� --� DEPARTMENT OF COI��IIvItJNITY&DEVELOPMENT SERVICES ,,t� �
�- � * � 21825 E.Cop[ey Drive � >
(909)860-3195 Fax(909)861-311'7 ' � PRESS
`%��� BUILDIPIG�ERMITAPPLICATtON FIRMLY
� JOBSITE /� J� ,n
o ADDRESS �� �,�� �(�tlJ��.LLSH Rf�1,+ DATECATION NUMB R '_���/C
� APN LOT lTRACT �SSUE TYPE OCC
DATE CONST. GROUP
p OW NER �L YYL A-�@. l.i t�.�-l � �
o ADDRESS , ZONING SETBACKS
Z CITY ZIP " ,3TEL S�E/- �`{ FRONT Ryy -
� APPLICANT C- M- TEL. REAR
z SIDE/SIDE STREET RW
'_ Q CONTRACTOR �% S SIDE _
� ADDR�55 lf��1 'I11.�C.._ s G J
0 CITY .J�'R�:,'2��i�+��= Z�p. , �+/ TEL._ ,j �02�j g i PROPOSED USE ,1 4 �
wo ARCHIENGi `E E� �N4� 6�
z DESIGNER
w NO.DWEL. NO. NO.
a ADDRESS
= CITY ZIP TEL. UNItS STORIES BEDROOMS
�
cn DESCRfPTfON SQ.FT. FACTOR PSF ADJ.AREANALUATION
� _ OWNER-BUILDER DECLARATION SFR/ADD/FEM
O
p I HEREBV AFFIRM UNDER PEN�'T�'OF PERJURY THAT 1 N.1 EXEMPT FROM iHE CONTRACTORS LI- GafaJB/C81p01Y
W CENSEUWFOR'HEFOLLOWINGREASON(SEC.70.11.SBUSWESSANOPROFESSIONSCDOE:AfJYCI'[YOR (f�
U CAUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE.DEMOLISN,ORflEPAIRANYSIAUC-
w TURE,PRIOR TO ITS ISSUANCE.AL50 REIX11RE5 THE APPLICANT FOR SUCH PERMiT TO FIIE A SIGNEO W Patio/Oeck
� STATEMEM THpT HE dR SHE IS LICENSEO PURSUANT TD THE PROVISIONS OF THE CANTqACTORS LI-
� CENSE UW(CHMTER 9(CAMMENCING WITH SECTION 7000)OF�IVISION 30F THE BUSINESS AND PflO� LL' PooVSpa
O GESSIDNSCADE)ORTHATHEORSHEISEXEMPTTHEREFROAIANDTNEBASISFORTHEALLEGEDEXEMP- �
U 710N.ANYVIOLATION0=5ECTION�031.SBYANYAPPUCANTWRAPERMITSI�.lECTSTHEAPPLICANTTO Z Re-Roof
� A CIVII PENALTV OF NOT MORE THAN FIVE HUNDRm OOlURS(SSOD).):
� ❑I,ASOWNEROFTHEPROPER7Y.ORMYEMPLOYEESWITHWAGESASTMEIfl50LECAMPENSATION, COfnfnefClHl
WILL DO iHE WORK,RNO THE S7RUCTURE IS NOT IN7ENOED OR OFFERED FOR SALE;SEC.7044,BU51- �
� NE55 AND PPOFESSIONS CADE:THE CDNTRACTORS LICENSc UW DOES NOT APPLY 70 AN OWNER OF ,
PROPER7YWH09UILDSORIMPROVESTMEREON.ANOWHOOOESSLJCHWORKHIMSELFORHERSELFOR �
� THROUGH HIS Ofi HER OWN EMPLOYEES,GROVIOE�THAT SUCH IMPROVEMENTS ARE NOT MTENOED OR m -
Q OFFEREDFORS/LLEIF,HOWEVERIHEBUILDINGORIMVROVEMENTISSOtDWITHINONEYEAqOFGOMPI.E
Z TION,THE OWNEfi-BUIIDER WILL HAVE THE BUR�EN OF PROYING THAT HE OR SHE DID NOT BNLD Ofl
� IMPROVEFORTHEPUPPOSEOFSAIE).
W ❑I,ASOWNEROFTHEPROPERIY,AME%CWSIVELYCANTRACTINGWITHLICENSEDCONiRACTORS
Q 70 CANSTRUCT TFIE PR0.IECT(SEC.7ou,9USINE55 AND PROFESSIDNS CODE:THE CONTRACTOpS LF VdlUBllOf1 ADJ.AREA
W CENSELAWWESNOTAPPLYTOAp10V/NEAOPAPROPERTYWHOBUIL�SOFi1MPROVESTHEREON.AND
� WHOCANTRACTSFORSUCHPROJECTSWITHACANTRACTOR(S)UCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION � � FEE
Y TOqS LICENSE L0.W.).
� �I AM EXEAIPT UNDER SEC. B.8 P.C.FOfl THIS REASON Q
?.� U
LL" DATE ONMER ¢
Z U
� UCENSED CONTRACTORS DECLAHATION W
d
� I HEREBYAFFIRM UNDER PENALTY Oi PERJURY THAT I AM LICENSED UNDER PF�VISIONS OF CHAPTEfi �
� 9�COMMENCING WRH SECTION 7000)OF DWISION 30FiTHE BU51NE5S AND PROFE5510N5 CODE.AND Z
� UCENSECLASSFULL�ORCi�EFFEqT.i�'�D � �� b j
`� l t
U OATE �� �Q� CONTRACTOR - G1 p�
W - (((
� WORKERS'COMPENSATION DECLARATION ��� �^ � :,I s �� ,�PO� .
/ 1K��
� I HEREBY AFFIRM UNDER PENALN OF PERJURY ONE Of THE FOLLOWING�ECLARAT S: — C �A�� �
� ��
Z _I HAVE AND WILL MAINTAIN A CERTIFtCATE OF CONSENTTO SELF-INSURE FOR WORKERS' _ �
Q CAMPENSATION,AS PROVIDED BY SECTION 3700 OF THE UBOR CO�E,FORTHE PERFORMANCE �U
Q OF THE WORK FOR WHICH THIS PEflMiT IS ISSUED. � .�
W _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE.ASREQIJIREDBVSECTiON
Q37o00F7HELABORCO�E,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERM1T15 -
ISSUEO.MV WORKERS'CAMPENSATION ItiSURANCE CARftIEF AND PO�ICY NUMBEfi ARE: CONSTRUCTION
J
� j -cnRRiER PLAN REVIfW
ZPOLICYNUMBER ELECTRIC
Q
� (iHIS5EC110NNE�NDTBE00MRE7mOFhEPERMTISFOqONEIM�DREDDOLWl4(Sioo)OqLE55} PLUM6ING �
Z I CERTIFY THAT IN iHE PERFORMANCc OF TtiE WORK FOR WHICH THIS PERIAIT IS ISSUED.1 MECHANICAL
G7 SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SOAS TO BECAME SL/BJECT TO THE
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGpEE THAT IF I SHOULD BECOME INSPECTION FEE
= SU&IECTTOTHEWORKERS'COMPENSATIIXJP OVISIONSOFSECTION3]OaOfTHEUBOR �•� ��
CO�,'SHiALLF�O.`RTHWITHCOMPLYVW�HO PROVI I NS. ISSUANCE
p OATE: • �y"v t APPLICANT: 1�"'� � SMIP .
W "�_::.._.... . .. _'_"'___
J WARNINGFAIWRETOSECUREWORKERS'COMP�NSATIONCAVERi.GEISUNLAWFUL,ANDSHALLBE ENERGVP/C � � �
LL SU&IECTANEMP'_OYER10CflIMINALPENPLTIESANOCMLFINESUPTOONEHUNDREDTHOUS�ND ENERGYPERMIT �
.r DOLLAflS(3100.000),IN FODITION TO THE COST OF COMPENSATION,�AMAGES AS PqOV�ED FOR IN , � �''
� SECTION 3]oe OF THE IABOq CODE,INTEREST,ANDATTORNEY'S FEES. �
aC � FETENTION FEE: f 1 I I ' ��I .
t
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEFEBYAFFlRM UNDER PENALTY DF PERJUPV THATTNERE IS A CONSTRUCTION LENDMG AGENCY
� � FOF THE PEFFORMANCE OF THE WOPK F-0R WMICH iH15 PERMIT IS ISSUED(SEC.309],ClV.C.�.
Z
._ .__.__.__.
j LENDER'S NAME
a
1'— L_NDEflSADDRE55 -
� .
� I CERTIFY THAT I HAVE FEA�THISAPPLICATION AND STATE TH4T THE A80VE INFORMA710N IS COR{iECT. TOTAL FEES
w I AGREE TO COMPIY WITH ALL CITV AN�COUNTY ORDINANCES AN�STATE L4WS RELATING TO BJILOING
d
� CONSTRUCTION,AND HEREBY AUTtfORIZE REPRESEM1TATIVES OF THIS COUNTV TO ENTEF UPON iNE
Z ABOVE�M TIONEO PfiOPERTV FOfl INSP^cCTiON PURPOSES. COMMENTS
o . P� �,�z.�,
_
� , PERAIITTE £ NT) n,I � {) �
VJ .GW ���L � ` .
� SIGNATUfiE OF PEFMI EE DATE
� . RECPI NO. PAIDBY VALIDATION .
WHITE—Department Copy.YELIOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy �