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HomeMy WebLinkAbout10079 CTI'Y OF DIAMOND BAR 1 � COMMUNITY DEVELOPMEIV`T DEPARTMENT .;,,,� . 21660 E.Copley DriveSuite 190 PREC'v`S` (909)860-3195 Fax(9Q9)861-3117 �"�'"� BUILDING PERMIT APPLICATION FIRMLY ;-. .. . ._, , . '� , ��.��.,D � APPLICATI�N PERMIT P/C � JOBSITE f, ` o ADDRESS � � �',�-"; DATE NUMBER �� # � � ISSUE� TYPE OCC APN T TRACT DATE _ CONST. GROUP p OWNER �C�� �'�� p ADDR SS .� % 6""a'•°'� ZONING SETBACKS Z CITY +jr ZIP TE � -�`�f'" FRONT RW ❑ g APPLICANT TEL. REAR ❑ ��,�, . SIDEISIDE STREET RW O � CONTRACTOR '� M� /�` �'�r q� - SIDE ❑ � ADORESS f. ✓`— PROPOSED USE � cirv u zi p��`3= ������ w ARCH/ENG! Z DESIGNER NO.DWEI.. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.F'f. FACTQR PSF ADJ.AREANALUATION cn . .,, , � OWNER-Bl:ILOER DECLARATION gFR/AOLUREM O p I HEREev AFFIRM UNDEH PENAITY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS ll- G0P0g0/CefpOlt W CENSELAWFORTHEFOLIOWWGREASON(SEC.7o31.58USiNESSANDPROFESSI0N5CODE:ANYCITYOR (J'J C.� COUNNWHICHREOUIRESAPEHMITTOCONS7RUCT,ALTER.IMPROVE,DEMOLISH.OqREpAtRANVSTRUC. W patiolDeck wTURE,PRIOH TO IT313SUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNm W � S7ATEMENT TMAt HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTHACTPRS ll- � CENSE LAW(CMAPTEP 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BU91NES9 ANfS�PRtl- � PooVSpa � FESSIONSCOOEIORTHATHEORSHE�SE%EMPTTHEREFROMANO71/EBASISFOHTHERLLEOE��EXEMP- - V TION.ANVVIOLATIdJOFSECTION703t.68YANVAPPUCANTFOHAPERMITSUBJE075THEAPPLICWJTTO Z RB•ROOf F A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOlLAR5(f500)): ' � � ❑I.ASOWNEROFTHEPROPER7v,ORA1VEMPLOVEESY7ITHWAGESASTHEIRSQL�COMPENSATiON. � COfnt116fClel Z WILL 00 THE WORK,AND THE STRUC7URE IS NOT INTENDED OR OFFERED FQ ALE(SEC.704l,Bt1Sl- J NESS AND PROFESSIONS CO�E:TNE CONTRACTORS LICENSE LAW DOES APPLV TO AN OWNER OF � VpOVERTVYM08UILDSORIMPROVESTHEHEON,ANDWHODOESSUC RKHIMSEIFOFHERSEIFOR m � THROUGH HIS OH HEROWN EMPLOYEES,PROVIDED TNAT SUCH IMP VEMENT3ARE NO7INTENDEDOR � 111 OFF[REDFORSAE.IF,HOWEVER,THE0111L01NGORIMPROVEME SOLDWRHINONEVEAROFCDUPLE• � TIOM.THE OWNEf48UIlDER WILL HAVE THE BURDEN OF PFl THAT HE OR SHE OID NOT BUILO OR Z IMPROVEFORTHEPLIRPQSEOFSALE). _ ❑I,ASOWNEROFTHEPAOPERTY,ANE%0.USIVE CONTRACTMGWffHLICENSEDCONTRACTORS � To CONSTRUCT THE PROJECT(SEC.7at4.BUSINES ND PROFESSIDNS CO�E:THE 60NTMCTORS LI- VSIUBfiOf1 ADJ.AREA W CENSEUWOOESNOTAPPLVTOANOWNEHOFA OPERNWHOBUILDSOR�MPROV�BTFIEREON.AND � WFqCONTMCTSiOFSUCHPRDJEGTSWiTHACANTRACiOR(SyGCENSEDPURSUANT?OTHECONTRAG (')UANTITY DESCRIPTION FEE Y TORS IICENSE LAW.j. � J L� 0 O I AM EXEMPT UN�EF SEC. B.8 P.C.FOR THIS RE�SON � �' a7 � OAT[ OWNEH � Z .��, � P a � LICENSED CONTRACTORS DECLARATION ' ` H � I HEREBY AFFIRM UNDER PENALTY OF PERJURY 7HAT I qM LICENSE�UN�ER PROVISIONS OPCHAPTER .w d e(COMMENCINO WITH SECTION 700D)OF�IVISION 3 OF TFiE BUSINESS AND PROFESSIONS CODE,AND X A/V UCENSE IS M FULL FORCE AND EFFECT. �,.�-..Qd�r ��p�^.� '_"� � LICENS �S � "�LIC.NO. �4�" � (�,,. '°�Z CGa�y ea'9-.�A V OATE'�� CONTRACTOR.• W .. s. .�' ..'.,..�.! � WORKERS'COMPENSATION DECLARATION� Q ����n.�jd, ^'� � I HEREBV AFFiRM UN�ER PENALTY OF PERJURY ONE OF THE FOLLAWING DECIARATIONS: � �p�,� �r a � O _IHAYEANDWILIMAINTAINACERTIFIGATEOFCANSEN7TOSElF�INSUREfOFlWORKE S'��• _ � ��(yT���st���eqint,Q,�, � �CAIAVENSATION.AS PROVIDED BY.SEC710N 370o OF THE LABDR CODE.FOfl THE PERFORMANCE W g�a' OF THE WOHN FOR WHICH THIS PERA7IT IS ISSUED. � � _� C O W _I HAVE ANU WILL MAMTAIN WOflKEflB CAMPENSATION INSURANCE,AS REQUIqED BY SECTION Q a7oo OFTHE LABOR DE,FOR HE PE f-0RMANCF F THE WORN FOR WHICH'fH15 PERh9T15 ISSUEA.MV WOR S'f PE ATU INSURAN CARRIER AND POLICV NUMBER ARE: CONSTRUCTION � CARRIER �� t PLAN REVIEW ZPOUCYNUMBER ;�, ELECTRIC Q , ,� (fHISSEcl1oNNEIDNo7eECOAAPLEiEDOFTNEPEPDMISFORONEHJNJREO 6� )oR PLUMBING Z I CERTIFY THAT IN THE PERFORMANCE OF TFiE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAI. � (�j SHALLNOTEMPLOVANYPERSONINANYMANNERSOAST08ECOMESUBJECTTOTHE � WORKERS'COMPENSATIONlAW50fdALIFORNU,ANDAGREETMATIFI5H0 LABECOME INSPECTIONPEE SU&1 TO7HEWOFlNERS'CAMP R YISIONS� ECTION FTHELA90R ���f C = 0 ,I S ry FORTHWITHCOMPLY WIT P S . �SSUANGE - O 7 - SMIP p DATE: � 7 APPUCANT: '- J ENERGY P/C , WANNING FAILUpE TO SECURE WORKERS'COMPENSATION CAVERA�E IS uNLAWFUL, D AL BE �y SU&IECT AN EMPLOYER TO CHtMINRL PENAlT1ESAND CIVIL FINES UP TOONE HUNDH T USAND ENERGY PERMIT DOIIARS(57a0.00D),INAD�ITIONTOTHECOSTOFCONPENSATION,OAMAGESASPROVI DF-0RIN � SECTIDN97DeOFTHELNBORCODE,INTEREST,ANDATTONNEY'SFEES. REYENTIONFEE: � CON5TRUCTION IENDING AGENCY PRE-ALT FEE: � I HEREBV AFfIRM VNDER PENALTV OF PERJURY THAT THEHE IS p CONSTRUCTION LENDWfi AGENCY � �- FOR THE PERFORMANCE OF THE WORK iOR WHICN THIS PERMIT IS ISSUED(SEC.30W,CIV.C.). Z W � LEN�EF'SNAME -- F— LEN�ER'SADORESS �� - . . . � 1 CERTIFV THAT I HAVE READ THIS MPIICATION/W�STATE THATTNEABOYE INF6RMATION iS CARRECT. TOTAL FE ES w IAGREETOCAMPLYWITHAIICITYANDCOUNTYORDINMICE5ANO5TATEUWSFELATINGTOBUIL�ING � �� - � CONS7RUCTION,ANO MEREBY AUTHOPIZE REPRESENTATIYES OF 7HIS COUNTY 70 ENTER UPON THE ' � �MENTIONE�PROPEfiTY FOR INSPE �O PUHPOSES. COMMENTS , O �=.7 . l�.s" �"� . . � . � � m P ITT E NM/E( IN7) e'',�' � 4 , _ cn � SIGNATUREOF ER ER DATE � = RECPT.NO. 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