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HomeMy WebLinkAbout16660 (32) _ _ _. �----- ----�-.__-- CITY OF DIAMOND BAR �� � � DEPARTMENT O�COMMiJNI'I'Y&DEVELOPMENT SERVICES 21825 E.Copley Ddve (909)860-3195 Fax(909)861-3117 PRE$S '"��n>��' BiJII.D�G P�RMIT APPLICATION FI RM Y � JOBSITE �/')Q� �,�.s �� �e APPLICATION �� �g PERMIT � P/C o ADORESS��j/J.7 �i� DATE J NUMBER # �o ISSUE ��' �f ONST. GROUP APN LOTj ���ACT�+� DATE e e _ p OWNER � �'`' ADDRESS 1" d . � ZONING SETBACKS Z CITY� ZIP TEL.;Z3�- � � FRONT RW ❑ p APPLICANT TEL. w S DE/SIQE STREET RW ❑ Z m CONTRACTOR �r�� �O SIDE ❑ ¢ ADDRESS . � CITY ZIP�i�Gl7C`TEL.Gl-�L,r_�V PROPOSED USE w ARCH/ENG/ �/� �"" //V • z DESIGNER W •—r-. NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION pC OWNER-BUILDER DECLARATION SFFVADD/REM O p I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT i AM EXEMPT FROM THE CONTRACTORS LI- Gfll'Bg0/C2fP01i W CENSELAWFORTHEFOLLOWING'bEA50N(SEC.7o31.5BU51NE55ANDPROFESSION5CO0E:A�VqTYOfl (n C.� COUNTYWHICHREqUIRESAPERMITIDCONSTRUCT,ALTEH,IMPROVE,DEMOI.ISH,ORREPAIRANYSiRUC- (yf - W TURE,PRIOR TO ITS ISSUANCE,A'L50 REDUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Pdtio/DeGk STATEMENT THAT HE OR SHE IS LICENSEO PI1RSl1ANT TO THE PROVISIONS OF TliE CONTFACTOFS LI- � CENSE LAW(CHAPTER 9(CAMMENCING WITH SECTION 7o00J OF�IVISION 3 Of THE BUSINESSAND PRO- V' POOUSpB FESSIONSCODE)OflTHATHEORSHEISEXEMPTTHEREFROMANDTHE8ASI5FORTHEALLEGEDEXEMP- (� � TION.pNYVIOLATIONOFSECTION'�7031.SBYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Root � A pViL PEIJALTY OF NOT���MORE TF{AN FIVE HUNDRED DOLU+RS(5500).): Z ' ❑4ASOWNEftOFTHEPROPERTY,ORM11YEMPLOYEESWITH�WAGE5A5THEIR50LECOMPENSATION, 0 Commercial � - WILL DO THE WORK,AND THE STRUCTURE IS NOT IN i ENDED OR OFFERE�FOR SALE(SEC.7044,BUSI- J � NESS AN�PROFESSIONS CODE:�HE COMRP.CTOPS LICENSE LAW JOES NOT APPLY i0 AN OWNER OF � PflOPERTV WHO BL11LD5 OR IMPP6VES THEREON,AN�WHO[lOES SUCH WORK HIMSELF OR HERSELF OR � �' THROUGHHISORHEROWNEMPLIJYEES,PROVIDE�THATSl1CHIMPROVEMEMSARENOTINTENDEDOR m Q OFFER�FORSALE.IF,HOWEVEP'R`'HEBUIL�INGORIMPROVEMENTISSOfDWITHINONEYEAROFCOMPLE- Z' T�ON,THE OWNEfl-BUILDER WILL'�nAVE THE BURDEN OF PROVING THAT HE Ofl SHE�IU NOT BUIL�OR � , IMPROVE FORTHE PURPOSE OF$ALE). ❑I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS � TO CONSTRUCi THE PROJECT(SEC.7044,eU51NESS AN�PROFESSIONS CO�E:THE CONTRAC70RS LI- Valua4io ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUIL�SORIMPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPRO,VECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAF QUANTITY DESCRIPTION FEE Y TORS LICENSE LAWJ. �� ❑i AM EXEMPT UNDER S�C. B.&P.C.FOF THIS REASON Q U LL � OATE OWNER H' � yVy! I � LICENSED CONTRACTORS DECLARATION � W � S . � CC IHEREBYAFFIRMUN�ERPENALTI'OFPERJURYTHATIAMLICENSEDUN�ERPROVISIONSOFCHAPTER � p: 9�COMMENCING WIiH SECTION 7oaa)OF�IVISION 30F TI1E BUSINESS ANO PF.OFESSIONS CODE,AN�J Z QMY LICENSE IS IN FULL FOP=E A�FFEGT. ���/ � � LICENSE C LI0.NO. � V �ATE O CONTRAGTOR � a L1J � WORKERS'COMPENSATION DECLARATION Q � � IHEREBVAFFIRMUNOERPENALTVOFPERJURV�JEOFTHEFOLLOWMGDECLARATIONS: Z Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF-INSUFlE FOF WORKERS' � ¢ CAMPENS ,ASPROl�lOEUBYSEC710N37a00FTHELABORCOOE.FORTHEPERFORMANCE W � OF T RK FOR WHICH THIS PERMIT IS ISSUED. � Qw I HAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSU ANCE,AS REQVIRED BY SECTION ,yy �+ / y 37000FTHELABORC E,F RTHEPERWRMANCEOFTH WORKFORWHICHTHISPEFMITIS �',�y� /�I / J ISSUED.RIV WO CQ ENSATION INSI��AN�POLICV NUMBER ARE: CONSTRUCTION t p� ¢� �.y'A...� y CAPRIE� �I � �d/ PLAN REVIEW ZPOUCVNUMeER ELECTRIC 4 0 (iHI55ECTICNNEmNOTBEOJMPLEfEDOF'fHEPERMITISWRIXJEHUNDREDCq1ARS(510�ORLESS). PLUMBING Z ICERTIFVTHATINTHEPE�IFORMANCEOFTHEWOPoGFORWH�CHTHISPERMITISISSUED,1 MECHANICAL � (,�j SHALLNOTEMPLOYANYQERSONINANYMANNERSO iOBECO ESUBJECTTOTHE b� �''�� � � ���' (r} WORNERS'COMPENSHTICJN LAWSOF CALIFOpNIA,A AGREE TH IP I SHOU ECOME INSPECTION FE� _��-' � = SUBJEC TO T �WORKERS'CtlMr'ENSATION PROV NS OF ION 3700 HE �� CODE, ORTHWITFf COMPLY WIiHTHOSE VISIO . ISSUANCE �_�� t—,� ✓ Q � / DATE: APPLICANT:_ SMIP �°� � L�� .e WWARNING FAILUFE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AN�SHALL BE ENERGY P/C � SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCNILFMESU7TOONEHUNDREDTHOUSAND ENERGYPEFIMI'�. ^ � YO THE COSTOF COMPENSATIDN.OAMAGES AS PROVIDE�FOR IN ,o� J SEOCTIORN370 OFTHELA90ROCODE,INTEREST,ANDATTORNEV'SFEES. I�ETENTIONFEE�w���~ ��������--� - OCONSTRUCTION LENDINGAGENCY PRE-ALT FEE: � I HEREBV AFFlRM UNDER PENALTY OF PERJI fiV THATTHERE IS A CONSTfiUCTION LENDING AGENCV FOR THE PERFORMANCE DF THE WORVC FO W H THIS PERMIT IS ISSUE�(SEC.303],CN.C.�. , W � LENDER'S NAME _ F— �LENDEfl'SAD�ftE55 ,J � I CER7IFY THAT I HAVE READ THIS�qppLICATION AND STATE THAT TNE ABOVE INFORMATION IS COqRECT. TOTAL FE ES �y J ��� W 1 AGREE TO COMPLV WITH ALL qT1'AND WUNTY ORDINANCES AND STAiE LAWS FiELAT1NG TO BUIIDINO " 4�° r � CONSTflUCTION,ANDHEflEBYAUiTHORIZEREPRESENTATIVESOFTHISGOUN7Vi0ENiERUPONTHE � � ABOVE�v1eNTIONEDPROPEflTYFbRINSPECTIONPURPO5E5. - Z COMMENTS - � J � __—_ m PENMITTEENA RINT /` ¢ � / � �� � � �. � 1 Uj SIGNATU OFPERMITTEE ' D E = RECPT.NO. 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