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HomeMy WebLinkAbout16619 (20) �` CITY OF DIAMOND BAR � � DEPARTMBNT OF COIvIl�1UNTI'Y&DEVELOPMENT SERVICES � '� u 2 L 825 E.Copley Drive (909}860-3195 Fax(909)861-3117 pRESS �"%��^'�' BUILDING PERMIT APPLICATION FI LY � JOBSITE p.. j,�� /� �,,1 Q ADDRESS_�L� �� �G"l��j�\ V y��r�� APPLICATION PERMIT � P/C p ,-_-�._-,�.�_ DATE NUMBER #_ � ISSUE TYPE bCC APN LOT 7RACT DATE � � CONS7. GROUP � OWNER � o ADDRES v1C - 1� � ZONING SETBACKS 0 z CITY t C ZI TE(z � C� FRONT RW ❑ � APPUCANT TEL. REAR ❑ Z SIDEJSIDE STREET RW ❑ ¢ CONTRACTO ,�������� SIDE ❑ p� AD�RESS e G� " " o CITY�3t��s�,;�-3� ZIP �`- 1� EL. �(r"j,-��a.$� , ROP��SE� � sc• �� r' P w ARCH/ENG/ • z DESIGNER Yli/ � w !T NO.DWEL. N0. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BE�ROOMS u� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLAFATION SFR/AD�IREM O Q I MEREBY AFFIRM UNDER PENALTY OF PERJUqY THAT I AM E%EAIPT fROM THE CONTRACTORS L'- Gel'890/Cfl�pOft W CENSEIAWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANDPROFESSIONSGODE:ANYCITYOR (n ZCOUNTVWHICHREOUIRESAPERMITTOCONSTflUCT.AL7ER,IMPROVE,DEMOL15H2ORREPAIRANVSTRUG W P8�10l�BCk � TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOP SUCH PERMIT TO FILE A SIGNED W . STATEMEMT THAT HE OR SHE IS LICENSED Pl1R5UANT TO THE PROVISIONS OF iHE CONTRACTORS L6 � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF�IVISION 3 0F THE BUSINESS AND PRO- V' PooVSpa � FESSIDNSCODE)OpTHATHEORSHEISEXEMPTTHEREFROMA4DTHEBASISFOfiTHEALLEGEDEXEMP- (� U 710N.ANYVIOLATIONOFSECTION7031.SBYANVAPPLICANTFORAPERMITSUBJECT57HEAPPLICANT70 Z Re-Raof A GIVIL PENPLTY OF NOT MORE THAN FIVE HUN�RE�DOLLARS(S50D).): ZOI,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOI�COMPENSATiON. D Commercial WILL DO THE WORK,AND THE S7RUCTURE IS NOT INiENDED OR OFFERED FOR SALE(SECJoao,BU51- J � NE55 AND PROfESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOT APPLV 70 AN OWNER OF � PROPERTY YlMO BUILDS OH IMPqOVES THEREON,AND WMO�OES SUCH WORK HIMSELF OR HERSELF OR � THROUGHHISORHEFONMEMPLOVEES,PROVIOE�THATSUCHIMPROVEAAENTSARENOTINTENDEDOR m QOFFEREOFORSAI.E.IF,HOWEVER,hiEBUILDiNGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMP4E- Z TION,THE OWNER-BUIL�ER WILL HAYE THE 9UR�EN OF PROYING THAT HE OR SHE DID N07 3UI_�OR � IMPROVE FORTME PURPOSE OF SALE). ❑I,AS OWNER OF THE PROPERTY,AM EXCll�51VElY CONTRACTING WITH LICENSED CON7RACTORS q � TO CONS7RUCT 7HE PROJEC7(SEC.7D4a,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS L'�- Vdl GO ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEflOFAPpOPERTYWH09U14�50RIMPFOVESTMEREON,AND � WHOCONTRACTSFOq5UCH7ROJECTSWITMA('ANTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANT OESCRIP710N FEE Y TORSLICENSELAW). � ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON J � a � U ti.. � DATE OWNER U Z W � LICENSED GONTRACTORS DECLARATION W 4 2 IHEREBYAFFIRMUNOERPENALNOFPERJURYTHATIAMLICENSEDUNDERFROVISIONSOFCHAPTER � p,. 9(COMMENCING WITH SECTION 7o0a)OF DIVISION 3 OFTHE BUSINESSAND 7ROFE55I0NS CODE,AN0 Z 1X M7 UCENSE IS IN FULL FORCE ANO EFFECT. m �� � � LICENSE CLASS � LIC.N0. ,� � V DATE_ p CONTRACTOH�_ �' a W � WOAKERS'COMPENSA710N DECLARATION a � IHEREBVAFFIRMUNDERPENALNOFGERJURYONEOFTHEFOLLOWINGDECLARATIONS'. z O _�NAVE AND WILLMAINTAIN ACERTIFICATE OF CONSENTTO SEIF-INSl1RE FOR WOFKERS' a � MPENSATION,ASPFOVIDEDBYSEGT!ON3�o00FTHELAWRCODE,FORTNE7ERFORMANCE W �THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � F,W.. � I HAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS Rc'OUIRED BV SECTION dQ 37000FTHELAEOFCODE,f-0RTHEPERWRMANCEOFTHEWORKFORWHICHTHISPEflM1T15 IS6UED.MY WORKERS'COMPENSATION INSURANCE CAFRIER AND POLICV NUMBER ARE�, CONSTRUCTION I `t caaatEa -r ''(�5 _. �L"I�.-a`1 � ����-i�' PLAN REVIEW � POUCYNUMBER � '4� � �J ELECTflIC ' ¢ �'J� ��V fi"" ,f."9 7 J� �� L�� �,, '� (MISSECTiONNEQ�NO78EC0 R� O E{{ ISFOR HU�+AREpD�} (E100)ORIESS]. PLUMBING ( L /yJp "[�,e,Y�G G� Z ICEflTIFYTHATINTHEPERFO�ANCE'CF HE`W'O FO IC�THIS�ERMIfISISSUED,I MECHANICAL � SHALL NOT EMPLOY ANY PERSOM IN ANY MANNER SOAS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA.AN�AGREETHATIFISHOULDBECOME INSPECTIONFEE = SUBJECTTOTHE WORKEFS'COMPENSAT'�ON PROVISIONS OF SECTION 37o00FTHE LABOR ' COOE 1 SHqLL FOftiHWITH COMPLY WITH THOSE PROVISIONS,,�,/ .A ISSUANCE � O OATE:� APPLICANT:�t fL'�i i C.PP��' I�LR A ���SY�'R _ SMIP b � WARNWGFAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL.,ANDSHALLBE ENERGYP/C •—^---�^-'�`�—^ LL SUBJECTANEMPLOYEFT�CRININALPENAITIESANDCIYI:FI4ESUPTOONEHVNDRLO7HOl1SAN0 ENERGVPERMIT DOLLARS(S�OD.000�,IN AD�ITION TO THE COST OF COMPENSATIIXJ,DAMAGES AS PflOVIDED FOR IN J SECTION3]oeOFTHELABORCODE,WTEREST,ANOATfORNEV'SFEES. RETENTIONFEE: � nW, CONSTRUCTION LEND�NG AGENCY PRE-ALT FEE: � -- � i MEREBY AFFIRM UNOER PENALTV OF PERJUPY THAT THERE IS ACONSTAUCTION LEND�NG AGENCY FOR'HE PERFORMANCE OF THE WORN FOR WHICH THIS PEiiM1Ti5ISSUED(SEC.3097,CIV.CJ. z w � LEN�ER'S NAME F-� LENDER'SADOFE55 � ,f� � ICERTIFYTHATIHAVEREAOTHISAPPLICATIONANDSTATETHATTNEABOVEINFORMATIO415CARREC7 TOTAL FEES � � V � I AGREc TO COMPLY WITH ALL CITY AND COUMV ORDINANC[S AN�STATE LAWS RELAT.NG TO BUILDING � � CONSTRl1CTION,AND HEPEBV AUTIiORIZE REPRESENTATNES OF THIS COUNTV?O ENTER UPON THE Z ABOVE-MEMIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS � J � % � m P'eR �A T�. [/,�� p�p,� ¢ Ys� V � � SIG TUREO PERMITTEE �� i[ = RECPT.NO. PAID 8Y VALIDATION ~ WHITE—Department Copy,VELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GRE N—Applicant's Copy , .' 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