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HomeMy WebLinkAbout13690 1�� CITY OF DIAMOND BAR � DEPtLRTMENT OF COMMUNITY&DEV�LOPIvIENT SERVICES � 21660 E.Copley Driva Suite 190 se� W (909)860-3195 Fax(904)861-3]17 PR ESS BUILDYNG P���T APPT.YCAxTt�N , , . _ .x...,.<.�.a.�. .., .... ,..._., . .. � _�;: , FIRMLY � SSUE �� N. ... ...,�, ., . ,,� u , .. .� ,.„ .�..M: , � JOBSITE 9nL��� }f��,��r,�G�,,.r^�' APPLICATION PUMBER ' �� � #, �✓� " a ADDRESS ��� ('r !'K�s ,� J r,�y TYPE OCC � APN---�- LOT TRACT ! f�d DATE CONST. GAOUP p OWNER ���. � NV S T { � ADDR SS 4 U✓ �i ZQNING SETBACKS Z CITY ZIP FRONT RW ❑ g APPLICANT ! TEL�J�� REAR ❑ � y SIDE(SIDE STREET_ RW ❑ CONTRACTO � C,- f �"L'.LD SIDE ❑ v CITY SSL' � 1 ~ZIP �� TEL. ' � PROPOSEJ USE �l��Ii I��d3 w ARCH/ENG/ �;Jf,D �� ���,, DESIGNER � ,���-�-- N ADD �S �Y �/�St 1"�— �'.� y UNI SW�L STORIES B DROOMS � CITY �-- �' 21P�� TEL ` v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADD/REM O I HEREBY AFFIRM UNDER PENALTY OF PEPJUM THAT I AM EXEMPT FROM 7HE CONTRACTORS LI- G8f8g0/C2fFWlt W CENSELAWFORTHEF011OW1NGREASON(SEC.7W1.68USINESSANDPROFESSIONSCODE:ANYGITYOR (n G� COUNTYWHICHREIXPqESAPERMR'f0-CONSTRUCT,ALTER,IMPflOVE.DEJuIOUSH,ORREPAfRANYSTflUG W Pdtio/DeCk � L NRE,PRIOR TO ITS 6SUANCE,AL50 REQUIRE5 THE APPLICANT FOR SUCH PERNIT TO FICE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTqACTORS LI• � � CENSE LAW(CFiAVTEH 0(COMMENCINO WITH SEC710N 7000)OF DNISION 1 OF THE BUSME5SAND pR0- �'i' POOVSpfl FESSIONSCODE)OATHATHEORSHEISfXEMPTTHEREFROMANDTHEBASISFORTHEALLEGE�EXEMP- (� TWN.ANVVIOLATqNOFSECT10N703t.5BVANYAPPUCAMTFORAPERMITSU&IECTSTH[APPLICANTTO Z Re-Rooi � ACML PENALN oF NOT MORE THAN FIVE HUNDRED DOLCARS(35ao).)i � ❑I,ASOWNEROFTHEPfiOPER7Y,ORMYEMPLOYEESWiYNWAGE5A5TiEIH50LECAMPENSATION, 0 Comm6fCial -- Wllt 00 THE WOPK,AN�THE STRUCTURE IS NOT IkTENC1ED OR OFFERE�FOR SALE��SEC.701b,OUSI- � NE55 AND PqOfE5510NS COOE:THE CANTRACTORS IICENSE U�A`DOES NOTA?PLY TO AN OWNER OF N PHOPERTYWF108UILASORIMPROVESTHEREON.ANDWHODOESSUCHWOpKHIMSELfOFHERSELfOR = <� . I � THFmUGH HIS OpHEROVM pdPLOYEES,PROVIDEO THAT SUCH IMVROVEMENTS ARF_NO71N7ENpE0 OH LL� OOFFERWFOFISALEIF,HOWEVER,THEBUIIDINGORIMpROOEAlEN71SSOLDWITHINONEYFAROFCOM�PLE- Z �TION,7HE OWNEN-BUIIDER WILL HAVE THE BURDEN OF PFiOVING'MAT HE QR SNE DID N4T BUIlD OR � IMPFIOVE FOR THE PURPOSE OF SALE). � ' ❑1,AS OWNER OFTHE PROPERTY,AAfi EXCLUSIVELV CdNTRACTING V49Tli UCENSED CANTRACTORS /� � TO CONSTflUCT THE PRQIECT(SEC.7044,BUSINE&S AND PROFESSIONS COpE:THE CONTqACTORS U- V1IU�IIOI7 __�/� ADJ.AREA�. -� W CENSELAWDDESNOTAPPLY701WOWNEROPAPROPERTYYYFI08UILDSORIMPROVESTHEREON,AND � z WFk�CONTHACTSFORSUGHPRdJECiSWI?4iACONTtiAC70R(S)UCENSEDPUASUANTTOh1ECANTRAG qUANTITY DESCRIPTION FEE Y TORSLICENSEIAW). � ❑I PM EXEMPT UNDER SEC. ___8.S P.C.FOR THIS REASON � k - 1,'-e''� LL _ � .. . , . -,. DA7'E ObYNER __ __ U �� UCENSED CONTRACTORS DECLARATION � `� � u, ---- -- I HEqEBYAFFIHM UNDER PENPLN OF PERJURY THAT 1 AM LICEIJSED UNDER PRONSIONS Of CHAGTER � B(COMMENCIMO WITH SECTION 7000)OF DIVISION 3 OF THE BUSIIJESS AND PROFESSIONS CODE,ANp z ,�y� + - ��� MY UCENSE IS W NI.L FORCE AND EFFECT. m � LICENSE CY.ASS � LIC.NO. � � � � J „ P DA7E �"� '--��9 CONTRACTOR_ � � � w <��.dc"0� f�'� "ayl.e.E,, �.) b � WORKERS'COt�IPENSATIONDECLAFATIOR ¢ 6���� �,r� ;., .,, r` ' � I HEREB AFFlRM UNDER PENALTY Of PENURY ONE C�THE FCJLL06+/ING DECLARATfONS: � r;,!��`J � ��AVEANDWILl0.1AlIdTAINhCERTIFICA7EOFCANSENTTOSELFIIVSUREFORWOqKER3' _ ' COMPENSATIDN,AS PAOVIOED BV SECTION 37000F THE LA84R COOF,FOR TLIC PEIYFOAMAR'CE � ' OF THE WORK FORM'NIGH Tw15 PERMIT IS ISSUED. � W I HAVE AND WILL AIAIMAIN WORKERS'COMPENSATION INSURANCE,AS REf�UIRE�8V SECTION Q y 37000F7HE LPBOR WDE,FORT.-0E PERFORMANCE OF Tt1E WORK FOR WHICN THIS PEPMIT IS .... � a0.- )93UED,MVWOftKEflS'WMPENSATIONIN3llii/WCECAfiH!ERANDPOLICYIduMBERARE: CONSTAUCTION -J . .. . . . _. . . ... . � _. .. > ChRFIER .�,��� 'c� � � POLICYNUMBER � ° � �'_--� 1 ¢ p �n+sS[cnonihlEH>tdoTB=_�EtEo�ixEa�twrr�srv�avEe�sraEO�i_eas�5loa)atLEss). � PLUMBING Z I CER7IFYTHAT IN TF9E PERFORMANCE OF PSiE WORK iOF WHICH THIS PERMIT IS ISSUED,i �ECHANICAL (;} SHALL NOT EMPLOY ANV PEHSON IN ANY NANNER SO AS 70 BECOME SUBJkCT TD'�HE 7 � WOfiKERS'COMPENSATIONLAWSOFCALIFORN10.ANDAAREETHATIFISHOULDBECOME 1�,N�,P„�e,IONFEE — SU&IECTTO iHE WOfiKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR ��' /'� CODE,l�S�HA�LL�FyORTkWITHCOMPLVWITHTHOSEPROVI510n5 � ISSUANCE� ' 1� � DATE:__e�='�6-"-([_ APPLICANT. _�` ���71(,�'�y��. i . wWARNING:FAILURETOSECUREWORKEHS'COMPENSATIDNCOVERAGEISUNLAMFUL,ANOSHALLBE E P�� A � SU&IECTAN EMPLOYEfl TO CRIMINAL PF7JALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT OOLL0.RS(51 o0.0oD).IN AOOIT�ON TO THE COST OF COMPENSATION,DNMAGES AS PROYIDED FOq IN � SECTION37080FTHELABOflCO�E,INTEPEST,ANDATTORNEY'SKEES. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-A��� � I HEAEBV AFFIRM UNDER PENALTV OF PERJURY THAT THEftE IS A CONSTRUCTION L'eNDING AGENCV g FOR TNE PEPFOflMANCE OF THE WORK FOR WHiCH THIS PERAAIT IS ISSUE��SEC.3097,CIV.C.). I. W • � LENDER'S NAME - — F— LENDEFi'SADDRESS _ � T TAL FEES ' W i CERTIFV THAT I HAVE READ THIS APPUCATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. � I AGREE TO CqMPLV WITH ALL CfTY ANO COUNTY OR�INANCES AND STATE LAWS REIATING TO BUILOING yyy'''��� � CONSTRUCTION,AN�HE0.EBYAUTHOfl12EREPRESENTATIVESOFTHISCOUNTVT6ENTERUPONTHE �i .�� (�A t� 'jJ � .�d Z ABOVE�MENTIONED PROPERTY FOR INSPECTION PURPOSES. MENTJ � U v����� � f _ __.�c��_��k�.�� qy m PEflMITT NAME(PRINT) - Y ¢ - � . . '�,�.i'�� � � � SIQNATU E OF PERMITTEE —'—'— ---'�'---'�A E -' -'-^�'��—�- � RECPT.PIO. � PAfD BY � � VALIDATION . 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