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HomeMy WebLinkAbout13352 ____�.� CITY OF DIAMOND BAR �� � DEPARTMENT OF COMMiJ1VITY&DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 ,;�,.; c�>s�o-�i9s���so9)s6i-3i i� PRESS BUIi,Dl�+TG 1��R11��'T,AI�]�LICATION � . ' ' "� FII�I�ILY JOBSITE ��v1 .:,�! Cs- 7 G�I`I+G"S J Sp UE A . ,. ..,,-, . ...,: . � . ,�, .�. _,,,,. ,,. . . :. _ N � � TiON C. --.��C� C�PEFiMIT /C o ADDRESS 5. DATE f �NUMBE��� � S TYPE OCC � APN LOT TRACT� �ATE CONST. GROUP p OWNER GI "f G o ADDRE S C1 20NING SETBACKS � CITY ZI ! � TEL RE�ART RW O APPLICANT _�.'�_ TEL SIDElSIDE STREET RW ❑ � CONTRACTOR SIDE ❑ p� ADDRESS � CtTY ZIP TEL. PROPOSED USE Q ARCWENG! z DESIGNER NO.DWEL. NO. NO. � ADDRESS UN1TS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION S�R/ADD/REM Q 8 1 HEflEBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FflOM THE CONTRACTORS I,I- Gdte90/�21pOfS CENSEtAWFORTHEFOLLOWINGREASON(SEC.7031.5@USINESSANOPROFESSIONSCODE:ANVCfTYOR (n CWNTYWHICHPEdJIF�SAPEHMRTOCONSTRUC7;ALTER,IMPROYE,OEMOLiSH,ORREPAIRANYSTql1C- W PaiIO/DP.Ck 7URE,PRIOR TO RS ISSUANCE,ALSO REWIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED - � -- w STA7EMENT THAT HE OR SHE�S UCENSEO PURSUAN7 TO THE PROVISIONS OF TH�CONtRACTORS L1- � � CENSE U1W(CHAPTEN 0(CAMMENCMCi WITH SECTION 70a0)O�'DNISION'9 0F THE BUSMESS ANO PR0- �'�' Poo�Spa � FESSIONSCODE)ORTHATHEOR3HEISEXEMPTTHEREFROMAN�TNEBASISFORTHE'ALLEGEDEXEMP- (� —'-- V TIOM.PNYYIOLATIONOFSECTION7o31.58YANYAPPLICANTFORAPERMITSU&lECTSTHEAPPUCANTTO z Re-Roof � A CPYII PEN,LLTY OF NOT MORE THAN FNE HUNDflED OOLLARS(3500).): � � ❑I,ASONMEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial - WILL DO THE WORK,AND THE STRUCNRE IS NOT INT'eNDED Oq OFFERE6 FOR SALC-(SEb.704A.BU51- _J � NESS ANO PROFESSIONS CO�E:THE COMRPCTORS LICENSE LAW DOES NOTAPPLY YO AN OWNER OF � P140PER7Y Nh10 BUILDS Op IMPROVES iHEAEON.M1D WHO DOEB SUCH WOkK HIIASELF OR NER5ELF OR • Q THROUCiHHISONHEflOWNEMPLOVEES,PFlOVIDE�THATSUCHIMPROVEMENTSARENOTINTENbE00R m n ,OFFEREDFORSILLEIFHOWEVERTNEBUILQINGbR1ASPROVEMENTISSOLDW!7HINbF1EYEAkOFCOMPI:E- � �TIOA1,7HE OWNER-NNIDER WiLL MAVE THE BUF�:N oF PROYINf3 THAT HE OR SHE61�NOT BUICD OR IMPfpVEFOR7HEPUfiPOSEOFSALE). � '' ' w ❑I,ASOWNEROFTFiEPROPERfY,PMEXCWSI4ELVCOMFt4CfINGKITHLiCENSE�COMRACTORS " [C TO CONSTRUCT TkE PRQIECT(SEC.7oB4,BUSINESS AND PNOFESSIONS COGE:YNF,f.ONTRACTtlRS LI- ValuBtion ADJ.AREA W CENSEUWDOESNOTAPPLYTDAIJOWNEROfAPFlOPEFTYWHOBUIL�SOR!MPROVESTHEREOtd,AND � WFIOCONTRACTSf-0RSUCHPROJEC7SWI7HACOtJTAAC70R(5}uCENSE�PUR5UAN7TOTFIECON7RAC- C�UANTITY pESCRIPTION FEE Y TORSUCENSELAW.). � _ � ❑I AM EXEMPT UNOER SEC. �9.G P.G FORTHIS REASON � .._ _�. ..,. .n�* �:4,�7'C ` r P'• ,.'.R, ''�1,4 �t,� �'`' DATE OM'NER___ . , 4 ... .. � ., �:� .x..�., . O _^_.__..__. � UCENSED CpNTRACTORS DECLARATIL)N � � I HEREBYAFFIRM UNDER PEf�AI.N OF PEHJURY THAT IAlA UCENSED UNDER PROVISIONS OF CHAPT'cR � Y(GVA/MENCIMOWITMSECTION7000)OFDIVISfON30FT71F8U51NF.55ANDPPOrE5510N5CO�E,AND . MY UCENSE IS CJ FUIL FORC AND EFFECT. ���o� . /'� ��� � ICENSE IX^�.A/$S _ UG NO. T � � 1 � ATE �J/ 3��° C CONTRACTOfl r � C�,G�y. —...__. .,,,-) �7 Y—� /''(�l(.� � WO+�KERS'CpPdAPENSATEON DECLARATI6N -� /a _ �2 g,� �;'� � � IHEFEBVAFFIRMUMDEHPENALTYO�PEPJURYO�EOfTNEFOLLOWINGDECIARATiONS: � .�, � Q: r � __I HAVE AND SNILL E9AINTAIN A CERTIFICATE OF CONSENT TO SELF�INSUfl'c FOR WORKERS' Z T� '� CAMPENSATiON,ASQROVI0EU6VSECTI0IVJ7000FTHElA80RCO0E,FOAThIEPERFORMANCE � �' OFTHE WORK FOC WHICHTHIS PERMIT IS'�.SSUED. � � � L 1 HA`JEAND WILL MAINTAIN WORKERS'CAM9ENSA7lON IP!>URANCE,AS R[qUlp,Cp 6Y SF_C'ION � ' r PE AT -i�- — EJ✓ORNFORWNIC47HI&PERNITIS � � E,FORTHEPERFOPAdAkCEO TY. ISSUED,MY WCRKE O� �� SURpN A R'�§f� �OLICY NUMBER ARE: CONSTRUCTION a7oo 0 ` p �� . . . .._-- __ ._..._.__. ._ � �y�RRIEfl . ��f"" d ' ���''--- PLAN REVIEW �... �.. . � � � PO��cYNUM9eR��.,r'�7g'�_��__ ELECTRIC Q (iH6SfC114VdNEf�NPTBE�IAPLE�'EACf7HEPEFfdlflSAHAVEHlNJ�6iE�DOi.LAA3(51W)ORLES>). PLUMB!NG � I CEFTIPYTHAT IN THE PEAF6RMANCE OF iHE WORK FOP,6YHICH TNIS PBR0.11T IS ISSUED.i MECHANICAL ?!�� �� '� SHAILPdOTEMPLOYANYPERSONINANYA9ANYERSbAST09F.COMF.SU9JECTTOTHE °'�'��" �� Uj WORKERS'COARPENSATIOtJiAWSUFCAUFCRNIA,kNDAGREETHATIFI5HIX1(.DBFCOUE ��SPECTIONFEE _ � $�S:'� .��e SU&IECT TNE WQRKERS'COMPENSA V151on�5 OF SECTION a7uo oF THE IABOR ' v` r ' ��' S co�,i qu. RTHWITH CAMPLY Wl�i,e. F�R�u�sSor:s. ISSUANCE `�`� ��,�� �� �' �-^--� p ATE:. _ ��_ APPUCAIVT:._ _ _,__ _,_______ SMIP _ � � '�,'�-��m.,,,�y J� ENERGY P/C �`a�«.�Q`� w�.'G°'��'a�. '' � � WARNI :FAILUFETOSEGUREWORKERS' P TIDNCOVERAGEISUNLAWFUI,ANOSHAL4BE - �---- SUBJECTAN EMPI.OYER TO CRIMINAL PENALTI D CIVIL FMES UP TO ONC HUNDRED THOUSAN6 "�•�-�"`� ' � O�.LAHS($100,000),INADDI710NTOTHECOSTCFCOMPENSATION,DAMAGESASPROVIDEDFORM ENEFGYPERMIT .r��s'�, ,�i � J SECTION37060FTHELABOFCOOE.INTEFEST,ANDATTORNEY'SFEES. RETENTIONFEE: '�+y,�_�4`!�'� d CONSTRUCTIOPI LENDING AGENCY '-����� PAE-AlT FEE: �� O w� � I HEREBYAFFIRM UNDER PF.NAITYOF PEPJURY THA7 THEilE IS A CANSTRUCTIfNJ 4ENDING AGENCY " � � � - - FOR iHE PEflFORMANCE OF THE W�RK F7R WH!CH TMIS PEflMIT IS ISSUED�SEC.3077.CIV.C.). , Z W � LENDER'S NAME F- LEIJDER'SA�DRESS W ICEi7TIfYTHAT11iAVEREADTHI5APPLICqT10NAN�5TATETNATTHEABOVEINFORMqT10NI5CARRECT. TOTAL FEES - ` � � I AGREE TO CAMPLY YYITH AlL CRY AND COUNTY OR�INANCES pN0 STATE LAWS PELATINC TO BVILOING � CANSTiiUCTION,ANDHEREBYAUTHORI2EREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE� Z ABOVE-MENTION'c0 PROPERTV fOR INSPECTION PURPOSES. COMMENTS_. � K'c� c� � _� QP Ryl E NAME(PRINTJ ' �. _ � � . _ '��y l (n SI T FPEflMITTEE �ATE ��� �. _ , REGPT.NO. 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