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HomeMy WebLinkAbout11358 � _ _. _ . . -- . . _ ..._ _ �. __. . _ _. . . _i . .. . . �. _ - ` s �---� CPI'Y OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT � ,,�;�,�;; 21660 E.Copley Drive Suite 190 P��S+a�+ (909)860-3195 Fax(909)8613117 � �'�"" BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE d� �'�o p( �y APPLICATION � CI�%+�,/� PERMIT P/C Q o ADDRESS '1.�`�� ,1'3,y��'d'��R�i'� YJ�:1i�/ �1�� DkTE :�°f'*" �t� 1�1 NUMBER ��� # ��+�� oro �n e , lSSUE yp TYPE OCC APN' LOTi 9 TRACT-' :� DATE ` � ffi CONST. GROUP p OWNER ' ���! � � ��'�I� ADDRESS � l.�'" .- 7,� ZONING SETBACKS � CITY ° $,�k��' ZIP �x TEL.�"".��� FRONT RW ❑ � APPLICANT� � TE ., -� �& ry REAR ❑ � SIDE/SIDE STREET ' RW � , Q CONTRACTOR , V �, .� � �. A SIDE ❑ � ADDRESS � " �-- � CITY Z!P TEL. PRQPOSED USE_����,��'�_���� � o ARCHlENG/ �z DESfGNER NO.DVJEL. NO. , NO: '��, ADDRESS UNITS STORIES BEDROQMS � CITY ZIP TEL. � DES TION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION �. . . - OWNER-BCILDERDECLARA710N � SF A lREM f � � � O p I HEREBY AFFIFM UNDEfl PENALTY OF PERIURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � G2.1'6q2/CafPOlt ' ' � ' � � W� CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.6BUSINESSANDPROFESSIONSCODE:ANYCITIOR U .GW�TYWHICHREQUIRESAPERMITTOCONSTftUCT,ALTER.IlAPROVE,DEMOLISH,ORftEPAIRFNYSTftUG- �J,J pytl0/�BCI( - �' � � ' z �FURE,PftIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PEPMIT TO FILE A SIGNED � W 'STATEMENT THAY HE OR SHE IS LICENSED PUFSUANT TO THE?FOVISIONS OF THE CONTPACTORS LI- W � �....'�CENSE.LAW(CHAPTER9(COMMENCINGWITHSECTION�Ooo)OFDNISION30FTHEBUSINESSAN�PRO- u' POO�SPd � � . , . '.F6SSIONSGO�E)OflTHATHEOR5HEISEXEMPTTHEREFROMANDTHc'BASISFORTHEALLGEDEXEMP- � - - ^- o TION.ANYVIOLATIONOFSECTION7o31SBYANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO -� RB-ROOf ' � �� � �AqVILPENALTYOPNOTMORETHANFIVEHUNDRE��OLLAP,S($5oo).�: Q; � � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIFSOLECOMPENSATION, 0 COf11f110fC18I ' ' ' � ' ' z �-WILL DO THE YJORK,AND THE STPUC7URE IS NOT INTFN�ED Oft�FFERED FOR SALE(SEC.7044,BUSI- J NE55 ANJ PROFESSIONS CODE:THE CONTRACTDRS LICENSE lAW DOES NOT AP7LY TD AN OWNEF OF � - �' � � "'� � PROPERTYVJHOBUILDSORIMAROVESTHEREON,ANDWHOOOESSUCHWORKHIMSELFORHERSELFOq � ' �� � THROUGHHISORHERONMEMPLOYEES,PROVIDEDhIATSUCHiMPROVEMENTSARENOTINTEN�EDOR m � , � � � � , � '�OFFEflE�FOFiSALEIF,IiOWEVER.THEBUILDINGORIMPqOVEMENTISSOLDWITHINONEYEAROFCOMPLE � Z� "TION:THE OWNER-BUILDER YlILL HAVE iHE BUR�EN OF PROVING TMAT HE OR SHE DID NOT BUi��OR , . , , ., i, i - � IMPROVE FORTHE PUflPOSE OF SALE;�. -- '�]I.AS OWNER OF THE PROPEFiII;AM EXCLUSNEIY WNTRACTING WITH LICENSE�CONTFFCTOPS � i0 CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONE CODE:THE CONTRACTORS LI- Vdltla[IOR � ' ADJ.AREA � �� W �, CENSEL4WDOESNOTAPPLYTOANOWNEROFAPFOPeRTYWNO6UILD50RIMPROVESTHEREON,ANb . -- � �' NhiOCONTRACTSFORSUCHPROJECTSWITHACONTFACTOR(5}UCENSEDPURSUANTTOTHECONTRAC- QUAMTITY DESCRIPTION � � ' �EE' ' � ' Y TORS LICENSE LAW.). / � ❑I PM EXEMPT UNDER SEC. 0.&P.C.FOR THIS REASON ¢ G.4/ /'j ' ' O V ODATE ..:i:tLV '"SF�3 6� �f� ONRJER V l�ti8 `� ,� .n��.J �� �g'✓I Ir��i Y � . ,. .I I � l � , LICENSeD CONTRACTOFS DECLARATION u � � ,. � I HEREBYAFFIAM UNDER PENALTV OF PEFJURY 1HAT I AM LICENSED UNOER PRONSIONS OF CFiAPTER ��. � , d, 9(COMMENCING WITH SECTION 7000)OF UtVI510N�3 0F THE BU5!NESS AN�PFOFESSIONS CO�E.PN� Z `X MY LICENSE IS W FULL FORCE AND EFFECT. m � . ' ' 6 ,S�''.' a.� � LICENSE CLASS LIC.NO. � j ^ � �'� � � �°'� �� ' J � 6.f0 � f! `�.{"'�y', �~' DATE GDNTRAGTOR � a- .w � � - ' - ���ByL�*'S . �,�i..va-f I'd'+t � � � WORKERS'COMPE��SATION DECLARATION a � � � �. '� �� � � a d7 ha. � � IHEREBVAFFIFMLIYDERPENALTYOFPERJURVONEOFTHEFOLLOWING�ECLARl1TION5: Z .i � _IHAVEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSELF-INSURF.FORWORKEPS' � ' ' ' ' ' ' a CAMPENSATION,ASPFOVIDEDBYSECTION37000FTHELABORCODE,FORTHEPERFORMANCE lU ' OFTHE WORK FOR WHICH THIS PERMIT IS ISSUE�. � . � � _IHAVEP.NDWILLMAINTAINWORKEP.S'COMPENSATIONINSU�9ANCE,ASFEDUIREDBYSECiION � ' Q 37naOFTHE LABOR CO�E,FOqTHE PERFORMANCE OFTHF.WORK FOR WHICHTHIS PERMIT IS ���F � Lh. ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLIGYNUMBERARE: �CONSTRUCTION ,.� j�, caaRieR ' PLAN REVIEW r -� Q ,�� POLICYNUMBEP ELECTRIC _/ �'dS��' �... Q. (11-IISSECiIONNEmNOTBECOMPLEfEDOFi}iEPERMRIS�-0RqJEHUNDFEDCOLWAS(S7W)ORLESS). PLUMBING ��p�.a�� �� , ICEflTIFYTFIATINTHEPERFORMANGEOFTHEWOFKFORWHICHTHISPERMIiI5155UE�,l MECHANICRL i l YQ'� � ',C!3. SHALLkOTE1APLOVANYoERSONINANVMANNERSOASTOBFCOMESUBJECTTO7HE �. �. �,(/� , WORKERS'COMPENSATIONLAWSOFGALIFOANIAANDAGFiEETHATIFISHOULDBECOME INSPECTIONFEE .� SUBJECTTOTHEWORKERS'CD6APENSATIONPROVISIONSOFSECTION37000FTHELAB�A ��.. '� " . �� GODE,ISHAIIFORTHWITHCOMPLYWITHTHOSEPROYI510N5. ISSUANCE '� sMIP 9v �,p DATE: _ APPLIGANT. _ �� ENERGY P!C ���� WAflNINGFAIWRETOSECUREWORKERS'COMPENSATIONCOVERAG'EISl1NLAWFl1L,AN�SHALLBE , ��,.�,�,- SUBJECTANEMPLOVERTOCRIMINALPENA_TIESANDCiVILFlNESUPTOONEHUN�REOTHOUSAND ENERGYPERMIT DOLLAHS(5700.006J,IN ADDITION TO THE COSTOF COMPENSATION,DAMAGES AS PROVIOED FOft IN ''.� SECTION37aBOFTHElA60RCODE,INTEREST,ANDATTOfiNEY'SFEES. RETGNTIONFEE: � -,,0., CONSTRUCTION LEN�ING AGENCY ' � CJ PRE-ALT FEE: I��"� IHEFiEBVAFFIRMUNDERPENALTYOFPERJLIRVTHAiiHERE15ACONSiRUCTION�LENOMGAGENCY � � ' ��'' FOR THE PERFO:MANCE OF TI-1E WOR'��(FOR WHICH THIS PERMIT IS ISSUED(SEC.309],CIV.C.�. � i j��.i LEIJ�ER'S NAME �I—�, LEN�ER'S A�ORE$S �� �'� I CEflTIFY THAT I HAVE REA�THIS APPLICATIONAY�STATE 1'HATTHEA80VE INFOFiAdFTION IS CORREC7. r �` R' ��,�� � T�TAL FEES a ' ``� �` � �' �� IAGREETOCOMPLVWITHAILCITYANDCOUNTVORJINANCESANDSTATELAWS,AELA7'�.NGTOBUILDING �"� CONSTRVCTION,AN�HERE6YAUTHOqIZEREPRESENTAT'NESOFTHISCOUNTYTO,EN7ER-UPOtvT E � � A90VE-MENTIONEO PflOPERTY FOR INSPECTION PURPOSES. COMMENTS � _�:�,��,� �r�i�-��.�� ��t��� m�, PERMITTEE NAME(P NT) ' � y� ����- ����� � �v,�p �'�j'.SIGI�A REOFPERMITTEE - DATE , _ � �' - - � � �� �� � - �� . � RECPT.NO. 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