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HomeMy WebLinkAbout17840 �,�` CITY OF DIAMONL7 BAR � - � DEPARTMENT OF CQMML;NTTY&DEVELt7FMENT SERViCES / � � 21825 E.Copley L}rive �� �go9�sbo-3 i9s F�i9o��a�i-3 i i� PRESS `'=q� BUILI}ING PEI2MIT APPLICATTON FIRMLY .� /� �. � JOBSITE �t����j--f`:�v� �✓-�=...—...— DATEICAT�dN 1�`� ` �UMBER �� �#/C � ADpRE5S�` 1 . � — — ISSUE TYPE OCC APN �OT TftACT _._ DATE CdNST. GROUP � OWNER O — " AdDRESS ZONING SETBAGKS z CITY ZiP TEL,� FRON7 _ RW ❑ g APPLICANT _ TEL. i REAf� 'J Z SiDE(SIDE STREET RW � � CONTRACTOR S SIDE C _ //��,,,..�� . . � ADdRESS_���'��_�� . . PROPOSED USE � CITYj��_i,���i_ Z!P�r'7l�t_ EL._�� w ARCF�ENG/ l��' �. wDESIGNER ��_._._,. Np.DWEL. NO. NO. c� ADDRESS UMITS STORIES BEDROOMS � CITY ZiP TEL. _� � DESCRIPTION SQ.FT. FACTOR PS� ADJ.AREANALUATION a QWNFR-BUILDER DECLARATICJN SFRlADplREM p _. I HEREBY AFFIRM UNDER PENALI'V OF PERIURY THAT I AM EXc'MGT FqdM TIiE CONTRACTORS LI- G8f8(JB/GBfPOfI LLI CENSEUWFORTHEFOLLOWINQREA$ON(SEC.7Ca1.58U51NESSAN�PROFESSIONSCAOE:ANYCITVOR (f? 4.3 GOUNfYWHiGNflE6UlflESAPEi#1ITTQCaNS7RUCT.ALTER.iM7Rft`JE,tSEM6li5H2ORAEPAiRANYSTRUG (j,j patiOlDBCk Z TURE,PRIOR TO IT$ISSUHNCE.ALSO RE�LIIRES THE APPUCAN7 FOF SVCH PERMIT TO FILE A BIGNED W w STA7EMEM'fHAT HE OR SHE I5 UCENSED aV415VANT T�THE PROV1910N5 OF THE CONTRRGTORS U� � CENSE lAW(CHAPTER 9(C�hiAAENCMG WITH SECTION)a00)6F DIV�^a�ON 3 OF THE BUSiNE55 AND PRO� � POOI/S(58 FESSI6NSCbDE�ORTHA7HEOp5HEISEXfiMPTTHEFEFROMANDTHEBASISFORTNEAL1.tGE�EXEMP- (�J � TI�N.ANYVIOLAilONQfSFG410N?031.�8YANYAPP�ICAN�FOftAPERMITSU&IEGTSTHEAP?tIGANTTD Z Re-Roof � A CIVIL PENAITV OF NOT hYJRE 7HAN FfVE HUNDRED DOLLARS�3500j.): � C11.ASOWNEROFTHE:PROPEFTY,ORMVEMPLOVEESWITHWAGEaASTHEIRSpLECOMPENSATION, � vommeraiai � WIIL�THE W4RK,Ari4 i HE STflUCTURE IS N07 INTENOED Ofl OFFEREO FOR SAI.E(SEC.Tbab,B�Si� � � NE55 ANO PflOFESSIONS(:ODE:THE CONTRACTORS LICENSE LAW DdES NOT AVPLV TO AN OWNER OF � PROPEPTYWHOBUILDSOFIIMPROVESTHEREON.ANDWHI?DOF.55UCHWORKHIMSELFOftHEASELFOY � CL THFiOUGHHISQRNEROWF7EMPLOYEES.PftOVlDEOTHATSUCH�MPROVEM6Mi5ARENOTiNTEN6EDOR � QOFFEREDFORSALE.IF,HON/EVER.iHEBUILDINGORIMPROVEIAENTISSOLDWITHINONEVEP,ROFCpMPLE� �, TION,THE OWNEft•BWL�ER WIU.NAVE THE BUPDEN�F PR01%1NG THAT HE Oti SHE DID NQ7 BUILD OR � 6ADAOVEFORTNEPURPO5EOFSAtfi}, ❑I.AS 4WNEROFTHI:PR4�ERiV,AM EXCLUSIVELY CONTRqCTING WITH UCENSE7 CONTRACTORS (��[ TO CAMSTRUCT TNE PR0.IECT{SEG.7034,BVS�NESS AN�PROF£5514NS GOQE:FHE CONTRACTOftS t'-- VdIUfftlOti ADJ.AREA W CENSEUWDOESNOTAPPLYT4ANpWNERDfAPFOVERTYWHOBUILD50qIMPRqVES7HEREQN,AND h WHOCONTRAGTSFpRSUCHPRqJEGTSWITHACONTRAC70R(S)IJCf.�VSEDPURSUANTTOTHECANTRAC- QUANTITY D SCRIPTION ^ FEE � T6RSUGENSELAW,}. � ❑I AM EXEMPT UN�EI;SEC. 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W � �ICENSEa GONTRACTQRS DECLARATI4N W � '- � �aC � I HEREBYAFFIFM UN�EF PI:NALTY OF PER.;URY THAT I AM LICENSED UNDER PROVISIaNSOF CHAPTER �, (i 8{GOMMENCMIG WITH SECTFOtY 74Cri)OF DIV75I6N 3 0F THE BUSINESS AND PROFESSK3N9 C06E,AtdD Z � � MYLIGENSEISINFUL���EFF� ���„ � . {�� m � LICENSE C 55 LIC.NO. . � � J � DATE ._� GQNTRACTOR��,,,{�,. . � �- c�i WC)RKERS'G4MPENSATtON DEGIARATiflN �`�� Q _ � U �� I HE,4E9Y AFFIRM UNDER PFNAITY�f PERJURY ONG OF TNE FOI.l,OWING DEC4ARAT1ON5. fh Z Q O I HAVf ANG WILL MAINTAIN A CERTIFIGATE qF CONSENT 70 SEI.F-INSUFE FfJR WDqKERS' 2 COMPENSATION,AS PROVIDE6 BY SEC710N 37COOF THE tABOfl C06E.FOR Tt{E PERF6MtM1GF U 4 oF iHE WQqK FOR�NHICH THIS PERMIT IS ISSUEd, � 4� W i HAYE ANp Will MAINTA�N WQRKERS'CO6iPEN5AilON INSllRANCE,A3 REQUIRED BY SEGTION � 3]o00FTHE LABOR C06E,FORTHE PERF(S�MANCE OFTHE WORK FOR WHICH THI$PERMITIS FSSUED.MY WQRKERS'CQMPENSAT}ON INSURANCE GARfliER APIQ P{}_tCY Nl3M8Efl AflE-. G'ONSTRUCTION , „_ _,_ d � cqaaiEA__ . .'(� .-- • PLAN REVlEW _..._.._... _ > , �n� •��--- � POL�CYNUMBER.,,��\.1V 1 1�...1 ELECTRIC .. �: d � � (R1tSSECiKNJNE87M1qTBEOJMFtETEpOFTHC4*CF3M1tITiSWRONENUf�DR:DDJ1.4Ail5rbtaa)ORLESSj, PLUMBING _ , W i CERTlFY THAT INTNE PERFORMANCE OF TNE WOflK FtsR W}itCN THfS PERMI7 IS iSSUEO.i MEGHANIGAI. � _—.�_ C,� SMALLNOTEMPLO�ANYPEFSONINANYMANNEFlSOASTOBECOMESUBJECTTOTHE � WORHERS'COMPENSATIONLAWSO�CALIFpFNIA,ANDAGFEETHATIFISHa4.1LDeECOMF. �NSPECTIONFEE __ ([��\J�— � SU8.7ECTtOTNEWC)RKERS'COMPENSAT16NPROVISION4c}F&ECTION3loDOF'HELABOFi �SSUANCE ��. •"O - —� CO I 5 L FOflTHWITM COMPLY WIT OJ E PROVISIO�y�,y� ._.� ,v .— � f / t�� } �^-— � 'p 17ATE:�4�4_ APPLICANT:����F� V..J�.�"• w!�' �" SMIP � ._ , � ENERGY P1G ._,._. .. J WARNiMG:FA0.URE 70 SECURE'h16RKER5 COMr�ENSATiON CAVERAGE iS UNtAWFUI,AND SHAli.BE � SU&IECTAN EMPLOYER Tp CRIMINAL FENALTIES ANCI CIVIL.FINES uP ipONE NI:NDRED THOUSANp ENERGV PERMIT D�lLARS{570�,000).!N AD�I(IOM TO THE CQST�F COMPENSATION,�AMAGFS AS PftDYIDED FOR IN � SECTION 37080F tHE�A86R CODE,iNT€REST,Ahip A7TORNEY5 FEES. RETENTION FEE: _^_,,,_„ , __ � GONSTftUGTiQN GENDtNG R6ENGY PRE-AtT FEE: _. O CC IHEREBYAFFI0.MUNDERPBVAL7Y�FPERJURYTHATTNE%EISAC�NSTR{�CTI�NLENDINGAGENCY d FORTHE PERFORMANCE OFTHE WflRK FOA WN�CH THiS pfaM�T I2I5SUE0 jSEC.30v'T,CIV C.}. ��� W � �ENOER'SNAME_.._.__.....�. _ ._ . ... � u i� tENpEft'SAS7DRESS_T_, _ - ' ` ` W IGERTlFYTMATIHAVEREADTNISAPPI.ICATICINANDSTATETHAT7HEAAOVEW=ORMATIONlSCORRECT. 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CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION I/ PRESS FIRMLY DATEICATION��,,, ��pERMIT����p/C UMBER # ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT Ryy^ REAR^ SIDE/SIDE STREET RW 0 SIDE^ PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION S0. FT FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM � Garage/Carport W Patio/Deck � PooUSpa Z Re-Roof � Commercial Ib Valuation ADJ.AREA QUANTITY D SCRIPTION FEE Q � �� LJ U U W LL1 � �� Z rD J a J Q u z Q z u w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING �� MECHANICAL INSPECTION FEE ISSUANCE yam] �- SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES� �� �}U� I COMMENTS ��� RECPT N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy