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HomeMy WebLinkAbout13309 CITY OF DIAMOND BAR \� `�---t�' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 ,. (909)860-3195 Fax(909)861-3117 PRESS .A� BUII,DING PI�f�Nt1`t'APpL�CATtoN. .:.... . ...,. � ._ri s.,r: ..0 . .. ,v.: .. . .. FIRM�Y ,.. ,., <. .� . �,.:. �� JOBSITE 2��Q�. ���� ���S� APPLICATION�_Z 9 ._� PERMIT ��Gr� P/C ADDRESS ! DATE P NUMBER # � ISSUE TYPE OCC � APN��L�'�_'�/�2-.�_B� TfiACT DATE CONST. GROUP p OWNER ��n/ �Rv� p ADDRESS ZONING SETBACKS � Cil'Y ZI TEL. � FRONT RW C APPUCANT � TEL. S DE/SIQE STREET RW C � CONTRACTOR C,k, 7.-�G.('tl�ri SIDE C � ADDRESS PROPOSED USE CIIY ZI TE�. o ARC NG � �z,, DESIGNER NO.�WEL. NO. NO. y ADDRESS UNITS STORIES BEDROOMS a CI7Y ZIP TEL. � v� DESCRIPTION SQ.FT. FACTOR f'SF ADJ.AREANALUATION � OWNER•BUILDER DECLAR&SION SFR/ADD/REM O I MEREBY AFFIRM UNOER PENQTY OF PEFiNFY THA7 I AM EXEMPT Ff➢�M 7HE CONTRACTORS LI- G3f8 J0/C81pOd W CENSELAWFORTHEFOILOYYINGREASON(SEC.7031.5BUSINESSAN�PROFESSbN5CADE:ANYCITYOR (n V COUNTYVNi1CNRE0UIRESAPERMiTTOCONSTRUCT,ALTEA.IMPROVE,�EMOIJSH,ORREPAIFANVS?pUa W P8f10/DBCk Z TURE,PRIOH TO 1T9 ISSUANCE;ASO REOl11RES THE APPLICANT FOR SUCR PERMIT t0 FILE A SIGNED w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PRDVISIONS OF THE�CON7HAC7'ORS�LI� W � CENSE LP.W(CHAP'TER e(COMMENCINO WITH SECTION 7o00)bF DNI$�ON S OFTHE 9USINESS AND PRo- �'�' POOVSp& FES910N8CO�E�ORhiATHEOR3HEiSEXEMPTTHEREF9tlMANDTHEBASI3FORIHEALLEGEDEXEMP- — TpN.ANVV10UTqNOF5ECT10N�037.5BYANYAPPUCANYKORAPEiiMITSUBJEGTSTHEAPpUCAN7Y0 � qe-Reof ��— � ACINLPENALTYOFNOTMORETHANFNEHUNOftE��OLLAtiS(550o):�: � ❑I,ASOWNEROFTHEPROPERT;ORMYEMPLOYEESWITHWhGESASTHEIFSOLECOMPENSATION, ❑ Commercial � - VlILL DO THE WORK,ANO THE S7RUCTURE IS NOT INTENDEb Of7 OF�ERE�FOR SAl.E�SEQ 7U44,0US6 ! � NESS ANO PROFESS�ONS CODE:hiE CANTRACTORS LICENSE LAW b�OES NOT APPLV TO AN OWPlEfi OF j PROPENTY WFb BU ILDSOR IMPROVES THERECN�,AND WHO DOES SUCH WORIC HIMS6LF OR HERSELF OR � THHOUGHHISORHEROWNEMPLOVEES,PROVIDEDTFiA75UCH�MPbOVEMENYbARENOTIN7EN�FDOR m � ,OFFERED�ORSAIEIF,��iOWNER,7HEBUILDINOORIMPROVEA'tENTtSSOLDWITHINONEYEA50FCbFAPtE� Z 710N,THE OWNER�URDEq WILL HAVE THE BURDEN OF PROVINO Tf1AT HE bR SHE Dlp NOT BWLD OR � IPIPf�YE FORTHE PURPOSE OF SALEJ. � � � ❑I,AS DtlIptER OF THE PROPEHi1;AM EJSCLUSIVELYC4NTRAL7MG NtRH Li^ENSE�CONTRACTORS � 7D CONS7AUCTTHE PflWECT(SEC.1044,BUSINESS ANO PROFESSIONS COL7Ei THE CONTRACTdRS U- VH1�184iOn_�_, _ADJ.AREA W CEkSEUW00ESNOTAPPLYTOANONRJEROFAPROPERNYAiG`BUILDSORIMPAOVESTHERFAN,ANO '— � Nrt1DCONTRAC7SFORSUCHPROJECTSWITHACONTRACTOR(5)UCENSEbr^URSUMTYC•THECANTPAG QUANTITY DESCRIPTION FEE - � TOAS 110ENSE UW.�. 1 0�. O IAM EXEMPT UNDER S�C. 8.d P.G FOR'rH15 RE0.SON Q � �� S� � .� � �� "s7 �A .C.. � OATE_ OWNER_�__ � F„ LICENSED CONTRAC70RS DECLARATION W . . .��..��, � .�� � I HEHEOY AFFIRM UNDER PENAITY OF PEFUURV THAT IAM lICENSED UNDER PROVISIONS OF CHAPTER � (�"�y a(COMMENCING WITH SECTION 7000)OF DNISION 3 OF TME 6U51!3E55 ANO PROFESSIONS COGF,ANp AC MY LICENSE IS IN FULL FOFCE ANO EFFEC7. � . L8.1 Q � LICENSECL4S5 <_;fU ___LIC.NO.��3� � ,,,,,�� � � � DAl'E� COtdTRACTOR � Ll.t / L "'�� � WORKERS'COMPENSATIOfJ DECL�F�I��I��r� N I HEREBY AFFIRM UNOER PENALiY OF PERJURY ONE CF'i HE F4LLOWING�F.CLARP710N5: �r y,� � �.. 0 __�HAYEANDWIL:MAINTAINACEA?IFICATEOFCAId5ENT7pSELF-INSUREFORWOPKERS' ^ �L COMflENSATION,AS PROViDED BY SECT!ON 3/C6 OF THE LABOR CODE,FOq THE PEHFORMANCE OF TNE WORK FQR WHICM 7HIS PERMIT IS ISSUEfI. � � _I HAYE PND W:LL MAINTAIN WORKERS'WM19?�NSATION IPJ,:.URANCE,AG R[OL9RED 8Y S[CTION Q 37o00F7HElA80RCODE,FORTHEPERFOR4IANCEGFTHEWORKFQRVNMICHTHISPERM!TIS !SSUED.MY WORKERS'OOMPENSA?IOh'IPdSURA7�E CARP,IER AND PO:ICY NUMBER ARE: CONSTRIJCTiON J ,c �I-/h j cnRRiEFl_.__�,�57.—�c�lr T---_ __—__ PL4N REVIEW }(°� � POLICY NUMBER__ i�a��_ �� ,_�/,(J— Q ��'� �� � � (IH63ECTI�NNE�NO7BEWM&I.E7EDOF7FEPEFriYTISFr�CtdEMMk�FiEDDOLV+RS(E�CajORLESS� PLUM1ABING .,�^t"`� r.:,�;�.;:r y I CFA7IFY THAT IN THE PERFORMANCE OF THE VdORH FOR WHICN THIS PFRMIT IS ISSUEO.l MECHP.NICAL L7 SHALL NOT E0.IPLOYANY?ERSOM IN ANY MANNER SOAS 70 EiECOME SUBJ[CT7if 7hiE � � WORKERS'COMPENSATIONI.AWSOFCALif-0RNIA,ANDAGpEETHATIFISHOUL06ECOME INSPECYIONFEE nC"^�� _.. �� /.p7^ � SU&lECTTO7HEWOF.KFRS'COIJP£NSATIONP�OVISIONSOkSECT10N37ooOFTHELA80R n ��,y g„ � ,�j,�- CODE,tSHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. �SSUANCE p3�� � �-.,�}`;�'.," e_� -�- � DATE:____._ AP?UCPJdT: _ —_—__—___—___—._ SMIP _��'���.��'`'���.q„h� . . . —'S WARNWO;FAILURE TO SECURE WORKERS'COMPENSATION COVEPAGE I5 UNLAWFUL,AND SHAl.I BE ENERGY P/C y� �_,+" '�*-°. LL SU&IECTANEMPLOYERTOCRIM�NAIPENALTIESANDCIVIIfINESUPTOONEHUNDflE�TFIOUSAN� '^��?„' y"; �'.���y� DOLLARS(5700.000J,IN ADDITION TO THE COSTOP COMPENSATION,OAMAGES AS PROVIDE�FOR IN ENERGY PERMIT . �,.� �,.J'4 .��:q �" � SECTI�N 37De OF THE LABOfl CODE,INTEREST,ANO ATTORNE`f5 FEES. RETENTION FE������;J QCONSTRUCTION tENDIhIG AGENCY PRE-AlT FEH: ������� � 1 HEREBY AFFIFM UNDER PENALTY OF PERJURV THAT THERE IS A CpNSTqUCTION IENDING AGENCY ___ FOR TME PERFORMANCE OFTHE WORK�-0R WHIGH THIS PERMI715155UED(SEC.3097,CIV,G.), . 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