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HomeMy WebLinkAbout16040 (23) ������ CITY OF DIAMOND BAR '"�""" -� " — DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �G'�,�i,�p/� 21660 E.Copley Drive Suite 190 w (909)860-3195 Fax(909)861-3117 � PRESS '":A«^� BUILDING PERMIT APPLICATION �='� . . FIRMLY �.- �� . _ issue � _��V�� :. r�Pe. . �. ... .. � ......., _,. :.,... � JOBSITE qPPLICATION PERMIT 1' P/C a ADDRESS �Q�'� G������r� DATE NUMBER �i � c� OCC APN LOT� TRACT DATE CONST. GROUP p OWNER ��'✓�� �I J�N i�� " ADDRESS ��?9 C�''��h'-�i � ,�/t- ZONING SETBACKS � CITY A�,d�+4� ZIP�(r+�"TEL. �o`!•S"9�l-GL�� PRONT RW ❑ APPtICANT TEL. REAR ❑ � V SIDEISIQE STREET RW O CONTFACTOR ���g.v�s /�,as Z,+oc SIDE ❑ � ADDRESS�,�Z -�"' � +�' y /�v%� � CITYl,aokE.s�}vc�/ ZIP�; rE�.6��-�s�6 �rii PROPOSEDUSE oARCH/ENG! z DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP 7EL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ,AREANALUATION � � OWNEfi-BUILDER DECIARAT10N SFRfADDlREM p I NEREBY AFFlRM UNDER PENALN OF PERJURV 7HAT I AM ExEMPT FROM THE CONTRAC70RS LI- GalagB.�C3fpOrt L3J CENSEUWFORTHEFq.LOWINGRFASON(SEG.703/.56USINE5511NDPROFESSIONSCODE:ANVCITYOR (n — ZCOUMVVYHICHREIX1IqESAPERM/RTOCONSTPUC7,ALTER,�MPROVE,OEAIOLISH,ORREPAIRANYSTfiUC- W pyti0lDBCk � TUPE,PRIDR TO ITS ISSUANCE,AL50 REQUIRES 1HE APPUCANT FOR SUCH PERMIT TO FILE A SIONED W STATELIENT TNAT HE OR SHE IS UCENSE6 PURSl1ANi TO iHE PROVISIONS OF THE CONTRACTORS LI� � CENSE lAW(CHAPTER B(COMMENGINa WRH SECTION 7ooaJ OF DIVISION 30F TNE BUSINESS AND PRO- u' POOUSpa FEC�.�^�ONS CDDEj OR THAT HE OR SHE IS EXEMPTTHEREFAOM ANO THE BASIS FOR THE ALLEGED E%EMP- V TION.ANYVIDLATqNOFSECTION7031.5BYANYAPP�ICAN7fORAPERMITSU&IECTST1EAPpUCANTTO � Re-Roof � ACJVILVENALTVOFNOTMORE7HANFiVEHUNDRE�DOLLAR5�;5oD).): � ❑I.ASOWNEROF7HEPROPER7Y,ORMVEMPLOYEESWITNWAGESASTHEIRSO�ECOMPENSATION, � CommBfCi81 YALL�O7HE WORK�ND THE STRUCTURE IS NOT INTENOED OR OFFERED GOR SALE(SEC.7044,BUSI� J NESS AND PiiOFESSIONS CODE:THE CONTRACTORS LICENSE LAW OOES NOT APPLY TO 0.N OWNER OF � PflOPERTYVfilOBUILD50RiMPROVESTMEREON.ANDVhiODOE55UCHWOflKHIMSELFORHERSELFOq � � 1}IROUQH HI60R HER ONM EMPLOYEES,VROVIDED THAT SUCM IMPqOVEMENTS ARE NOT iNTENDED OR m pOFFEREDFOflSAI,E.IF,HON/EVER,THEBUILDINGOHIMPROVEMENTi550lDWITHINONEYEAROFCOM%.E Z TION,THE OWNER-BUILDER WILL HAYE TNE BURDEN OF PROVWG THAT HF OR SHE 61�NOY BUIID Oq = IMPROVEFORTHEPURPOSEOFSN.E). W ❑I,ASOMRJEPOFTHEPROPENTV,AMEXCWSIVELYCANTRACTINGWRNLICENSEDCOMRACTORS � TO CONSTRUC7THE PRQIECT(SEC.70M,BUSINESS AND PROfESSIONS CODE:THE CONTRACTOflS LI- VdIUH110� ADJ.AREA CER'SE LAW DDES NOTAPPLV TO AN OVMEq OF A PROPERTY WHO BUILDS OR IMPROVF.S THEREON,AND � WFiOCONTMCTSFORSUCHPROJECTSWITHACONI'HACTOR(5}LICENSEDPURSUAVTTQTHECONTMC- QUANTITY D�SCf3IPTION FEE � TORSLICENSEUIWJ. — — — — ❑IAAA EXEMPT UNDER SEC.�__ B.6 P.G FOR THIS REASON Q 3 �i � LL' �P7E ON�NER__. �" Z W � LICENS�D CONTRACTORS DECIARATION -r � W I HEREBV AFKIRM UNDEIi PENALTV OF PERIURY 1'HAi I MA L�CENSEO UNDER PROVISbNS OF CHAPTER � (L. B(COMMENCINC3WITXSECTNNd7oa0)OFDIVISIDN30FTHEBUSINESSANDPROFESSIONSCO�E,AN� Z �f AIY�ICENSE IS 1N FULI FDRCE AND EFFECT. m LL1 R p � UCENSE CLA55 �L�___ LIC.NO. •��r�i�2�� � V OATE S S� t7��Z-- CONTRACTOR /'f[/- a W � WORKERS'COMPENSATION GECLARATION Q � U � i HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLAMTICNS: � � d 0 IHAYEANDWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUREFORWORKERS' _ � ^COMPENSATION,ASPROVlDEDBYSECT�ON37ooOFTHELABORCADE,FORTHEPERFORMANCE w OFTNE WOqK FOR WHICN THIS PERMIT I.S ISSUED. � 0 W �I HAVE AND WILL MAIMA�N WORKERS'COMVENSATION INSt1RANCE,AS RE�l11RED BY SECTiON Q 37(!OOF THE L1BQR CODE,FOR THE PER WRMANGE OF THE WORK FOR WHICH THIS PEAMIT IS - -- —i— ISSUED.MYWOflKERS'COMPENSATIONIT$URANCECARRIERPNDPOL!CYNUMBEqAflE: CONSTRUCTION � onnqtEfl_� E �'� �`'a • PLAN REVIEW 7 � POIICYNUMBER_j.(�k� ��`4' �'���� ELECTftIC Q /� 0 Cn+ssEcinraN�Ennarsec�nna���oFn�aEwKrswaorvErux�e000uar��aiar�oR:Ess1. PLUMBING -� ��� bFl�N� �r Z I CERTIFY THAT IN THE PERKORMANCE OFTHE WOPK F-0R WHICH TFi1S FERMIT{S ISSl/ED.I MECHANICAL (J SHALI NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO TNE � WORKERS'COMPENSATIONI.nWSOFCALIFOfiNIA,ANDAGREETHATIFISNOULDBECPME INSPECTIONFEE S SUBJECTTOTHEWORKERS'COMPENSATIONPROYISIONSOFSECTION37COOFTHElA80R ���'i� J '�� �':�a� ISSUANCE �"_ `1 -���� CqOE,ISHALLFOFITHW�TNCOMPLYWITNTHOS ROYISIONS. � E�ii o ���. �� SMIP �9r . . . p DATE: /"6-D1�� APP�ICAN7: � . � � / ENERGY P/C 8 r'.'�.��A�'e�".3.���..�°�x WARNING FAILUf:G TO SFCURE WOFKERS'CAMPENSATI�J COVE0.AGE IS UNLAWFUL,AND SHALL AE ..� 1����g. ����'�I' �y SIJ&IECTANEMPLOYERTOCRIM!NALPENALTIESHNOCIVILFINESUPTOONEHUNDREOTHOUSAND ENERGYPERMIT "�a���-'a` + pOlURS(E10�.000).IN ADDITION TO THE COST Of COMPENSATION.DAMAGES AS PROVI�ED FOR IN � SECTION37080FiHELA80PCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1NEREBVAFFIRMUNDEFPENALTYOFPERJURViHATTHEFEISACONSTRUCTIONLENOINGAGENCV _ f-0R 7HE PERFORMANCE OFTHE WORK WR WHICN THIS PERMIT IS ISSUED(SEC.3C9�,CIV.C.�. Z ____ _' W � LFPWCR'SNAME '_""_"" F= LENDER'SADDRE83 /{ ^� WI CFRTIFV THAT 1 HAVE REkO THIS APPLICATION 0.N�STATE THATTHEABOYE INFORMATION IS CARRECT. TOTAL FE ES n \� J� V � I AGREE TO COfAPLY WI7H ALL CI'V ANO COUNTY ORDINFNCES AND STATE L4VJ5 RELATING TO BWLDING X �Y � CANSTRUCTION.ANDHEREBYAUIHORIZeREPPESENTATIYESOFTNISCWNTYTOENTERUPONTHE ABOVEMENTIONED PROPEHTV FOR INS7ECTION PURPOSES. COMMENTS O � Sc�s"i'T_ �E l� — m PERMITT NAAAE VRINT� - f __ 4 b � � CNATUREOFPERMITTEE DATE = RECPT.NO. PAID BY VALIDATION ~ WH17E—DepadmeM Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDEN OD--File Copy,GREEN—ApplicanYs Copy � , x. , . ..,,� , ,.. , , . . ,.., . „�.: ..,,, ,. "- ,:�.,+, i�' �;.. :,.�.:., . 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