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HomeMy WebLinkAbout12321 (14) - — i _ _ ^ _�� CITY OF DIAMOND BAR - �� DEPARTMENT OF COMI4IUNITY&DEVELQPMENT SERVICES ' _ . „ 21660 E.Copiey Drive Suite l90 � � PRESS � (909)860-3 t95 F�(909)861-3117 "` ' ��^. . BUILDING PEIi1VIIT APPLICATION '�� � FIRMLY o ADDR'ESS ���� ��4de���� ��° APPLICATION !J�—'?)�,,,,l�8'' NUM6ER I Z�2� �IC DATE � �► � ISSUE G� ��TYPE OCC •- APN �07 TRACT ' DATE `'��o t'" 'CONST. GROUP W �� �"�'� . p OWNER �� ����a� �� ZONING SETBACKS Q ADDRESS� � Q `,'C' ZIP TEL�'��!'"��..a`-K��� FRONT RW ❑ Z ClTY �` E�* REAR C APPLICAN"f `�'' �-� TEL'3-fl3�?���-a��AI SIDE/SIQESTREET ' RW G ¢ � CONTRACTOR ' ����.� ��'� ���� PROPOSED USE ��`�" � �� i �t� '� , SID ADDRESS �G���,¢�,� t�� �R� ��z&E� & .,. r� , �e _� cirr a�. ��i��Nes�.. ziP �t� � �R�'3�:��fl� . �; '� �� a+� �a � t � , u�i ARCH/ENG/ � � TEL.�� �� �` . �,' � ���o�4�'�" � ADDRESS UNI SWEL. d�"�.��'�`� S QRIES��� ��.."��S NO. o. �' CITY ZIP TEL. r BEDROOMS ' � DESCRIPTION SQ.FT." FACTOR PSF ADJ.AREAIVALUATION' � . ��. ;� , OWNER-BUILDER DEQLARATIQN � . SFWADD/REM � �- � � � �� �� O ��, p; � I HEREBYAFFIRM UNDER PENALN OF PERNRY THAT t AM EXEMPT FROM THE CONTRACTORS LI- , � Garage/Caryort � W ' CENSELAWiORTHEFOLLOWINGREASON�SEC.7o37.5BU51NESSANDPROFES510NSCODE:ANYCI7VOR � _ �GS� , COUNTYWHICHHEIX11flE5APERMITTOCONSTRUCT,ALTER,IMPROVE,�EMOLISH,OfiPEPA1RANYSTRUC• '',W patio/Deck � .Z� CANT FOR SUCH PERMIT TO FILE A SIGNED �, ���ESSIONS CODE I R THAT�HE Ofl SHE 1S EJ(EMPTTHEREFRQ HE PROVISIONS OF THE CONYMCTOP9 L4 ACIVI�ENAwl.T��'D NOTMOREI��CENSEDPURSUANTNT POOVS 8 STATEMENT THAT HE OR SHE IS LI CEN56 LAW(CHAPTE99(COMMENCING WITH SECTION 700b)OF DIVISION 30F THE BUSINESS AND PRO 'u' P ) M ANO THE BA565 FOR THE ALLEGED EXEMP V o3t.5HYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO R2-ROOf � �, WAN FIVE HUNDRE�DOLLkRS(SSW)J� .� , / ❑I,ASOWNEflOFTHEPROPERN,ORMYEMPLOVEESYJITHWAGESASTHEIRSOIECAMPENSATION, COfIIIfIBfCIffI ,Z...WIt,LDO THE WORK,.ANO TNE STRUC7UHE IS NOT INTENDED OR OFFERE�FOfl SALE(SEC.7044,BU54 ,:.J . NE55 AN�PFIOFESSIDNS CODE:THE CANTRAGTOHS LfCENSE LAW�OES PlOT APPLY YO AN OWNER OF ' ��' ' PROPEATYWHOBUILOSORIMPROVESYHEREON,PNDWHODOESSUCHWOPoCHIMSELFOfiHERSELFOR '�,'�,m , � '�[LI THROUGHHISORHEROWNEMPLOYEES,PflOVIOEDTHALSUCHIMPROVEMENTSARENOTINTENOEDOR 'OiF REDFORSAA.EIFHOWEVE 7HEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROPCdMPLE- ' E R I , �'i �-TION,THE OWNER-BUIIAER WILL HAVE 7HE 6URDEN OF PPOVING THAT He OR SHE DID NOT BUIL7 OR � � � �� �� �IMPROVEFORTHEPUPPOSEOFSALEj. '. ❑I,A90WNEROFlHE PROPERTY,AM EXCLUSIVELV CONTRACTING WffH LICENSED CAMRACTORS �9 ,�„� , �� TO CONSTRUCT THE PHQIECT(SEC.�043,BUSiNE55 AND PROFE9SION5 CADE:THE CONTRFCTOPS LI- 81118IIOf1��, 4��d' � ADJ.AREA � I W�. .CENSElAW00E5NOTAPPLYTOANOWNEROFAPROPER7YWHOBUILD50RIMPFObESTHEREON.AND 4` . �, .�'�. ��"'WHOCONTRACTSFORSUCHPR0.IECTSWITFtACDNTRACTOR(S)LICENSmPURSUANT707HECONTRAG � QUANTITY � DESCRIPTION ' ' �"FEE ' �i �, � TORSLICENSELAWJ. .. J . . , , . . �' �I' ❑IAM57(EMPTUMDERSEO. 8.8P.GFORTHISREASON �U � �I� I�I',. � . , . �. . , . � . , �il �. �ATE OWNER � V � � ^ � W �', ���, LICENSED CONTRACTORS DECLARATlON � ��y ^ � '� �'. t HEREBYAFFIRM UNDER PENAIN OF AERJURV THAT IAM�ICENSED UYDFA PROVISIONS OFCHAPiER �,;�� , p��� �e(COMMENCINO WITH SECTION 7000)OF�IVISI�J 30F THE BUSINESSAN�PROFESSIONS CADE,AND Z , �.� MY LiCENSE IS IFd FULL FORCEAND EPFECT. m � ��� LICENSE CLASS ��� LIC.NO. �6����� ���� � I� ' � on� ���"�� corarwacroa ��'��1. aJ , w �I � WORKERS'COMPENSATION DECLARATION -i � Q ' I ���� IHEREBYFFPiRMUNDERPENALNOFPERJUpYONEOFTHEFOLLOWINGDECLARATIONS: � � � I � � Q I �i ,C�'� IHAVEANDWILIBdAINTAIPVACER'TIFICATEOFCONSEkTTOSELF-INSl1REFOAWORKERS' _ � ! �'��, COMPENSATfON,ASPROVI�EDBYSECT10N37�oOFTHELABORCODE,FORTMEPERFORli1ANCE W OFTHE WORK FDR WHICH THIS PERMIT IS ISSUED. � 0' ' �,1 HAVE AND WILLMAINTAIN WORKERS'COMPENSATION INSURAPJCE,AS FEQUIRE�BY SECTION /� � �I ��'���' 37ooOFTHELABCRCODE,FORTHEPERFbRMANCEOFTHEWORKFORWHICHTHISPERMITIS E -} � f %� ISSU�.MYWORKE..S' MPENSAT�ION^IN�S,U�HSANCECAfiR1ERANDPOLICYNUMBERARE: CONSTflUCTION � t b� ' �i �R��� cnaaiea � � ' ��.;�°�^�a5"� PLANREVIEW � . . . . I�� �'' poucr NUMeER' � �8"�""��" ELECTRIC _ Q (THISSECTIONNE�NOTBECOPARECE�OFhiEPEFWYTISFOHOPdEHU�9REDWlVJi91$tao)ORLESS} PLUMBING II� ����. 1 CEHTIfYTHA:INTHE PEHFOAMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANICAL �'� ' ,�� SHALlNOTEMPLOYAtJYPERSONINANYAAANNER50ASTOBECOMESUBJECTT0T4E � WORKFAS'COMPENSATiON UWS OF CALIFORNIA,pND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE II �I ��" SU&IECTTOTHE'WORNERS'COMPENSATIONPROVISIONSOFSECT�DN37o00FT4ELABOR 2 '�"'� CAOE�,I ES�HALL FORTHWITH CANPLY WITH THOSE PftOVI51O''°N�5. ISSUANCE �I II �',�:, DATE: �~`�",�i�� APPLfCANT: �'u�+�-��R SMIP � 1�O i � ENERGY P/C .� WARNINGFAILUflETOSECUREWOFKERS'COMPENSATIONCOVERAOEISUNLAWFUL,ANDSHALLBE ', I ''�!',�'':'' 9U&IECTANEMPLOYER70CRIMINALPENALTIESANDCML�FINESUPTOONEHUNDREDTHOUSAND i I '�.�cu�,�. EPlERGY PERMIT '� ' OOLL4RS($700,000),INAD�ITIONTOTHECOSTOFCOMPENSATpN,DAMAGESASPROVI�EDFORIN � ��i ���.'�, SECTION37oeOF'fHELA80RCODE,INTEREST,ANDATTORNEV'SFEES. ' q�ENTIONFEE: '��, p„�� CONSTRUCTlONLENDiNGAGENCY PRE-ALTFEE: I�, .�'���,.' i HEAEBY AFFlRM UN�ER PENA�TV OF PERJURY THATTH�RE ISACONSTRUCTION LENDING AGENCY . FOIiTHEPERFORMANCEOFTHEN'ORKFORWHICHTHISPERMITISISSUED(SEC.3o97,CIV.0.�. . i �� � 1.6:1� . . � , , �',�. � LEN�ER'S NAME � � �', �F�`�.�. LENOER'SADDRESS .. .� � , � i ��ryryry^^^���' TOTAL FEES . I CERTIFY THAT 1 HAVE READ THIS APPLICA710N AND STATE THATTHEA90VE INFORMATION IS CARRECT. }^'' � I,'� IAGREE?OCAMPLVWIFHALLCIlYANDCOUNTYORDINANCESANOSTATELAWSRELATMGTOBUIL�ING � �� � � I/� CONSTHUCTbN,ANOHEREBVAUTHOWZEREPRESENTAi1VESOFTHISCOUNiVTOENTERUPONTHE �I J �, � �, ABOVE-MENTIONE�PROPERTV FOR ENSPECTION PURPOSES. COMMENTS � � I �' �i��� '�� (�. 2�� . P AME(PHINT) gy pg�e� ! I �I� °- �.� $ q � � �� M1 i7d � . ��.. ss OF P MI ��EE DATE RECPT.NO. O PAID BY ZS�� � �- VALIDATIOf� � !i �' - - � WHITE—Dapartment CoFY,YSLLOW—Finance Copy,PINK—Assessor Copy,�OLDENROD—File Copy.GREEN—Applicanfs Copy � � „ .. , , ;,:; . . . .,-.� < .. . . _ .. , , ���� �� ��� .����� � ��������� � � � ��� � � � � �� � � � � � Y � � � � V � � �' � ' �� F f .� '� , ' �. : � . . . '. ��., �': ��. i g p-; r-; .^^�, �^ �ww.s^Y"`���3 i'�; l �._.}_,�....�. . � , {� . �L.',=3b.1€"1�"��v€ x . 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