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HomeMy WebLinkAbout13003 (14) � �. CITY OF DIAMOND BAR � -- "—��— DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES � w 21660 E.Copley I7rive 5uite 190 ,; (909)860-3195 Fatc(909)861 3117 PRE$`S .�.,. Bvn��r��PI�RMrr A�i�`r,�CA7�biv �, FIRMLY . , ANb H„...: ..,., . „� , y ...._APP�ICATION' ` v PERMIT P/C�.., . .... ,_..,, .. .:.,.,. _.. . .,, M � z�,,,� � JOBSITE o ADDRESS� � � DATE v� NUMBER �---� # � APN LOT TRACT ( �SSUE TYPE OCC DATE CONST. GROUP p OWNER � � � o ADDRESS� . r `1 ,�,�,}��"�,,, • . ZONING SETBACKS OCITY �_ ZIP�(J�7 t�:7TEL � ; FRONT RW ❑ APPIICANT 7EL REAR ❑ G SIpElSIDE STREET RW � � CnNTRACTOR 6 , �,,+ � � SIDE ❑ pC ADDRESS PROPOSED USE �..,. � CITY 3 Z P / TEL: a . o ARCH/ENG/ „ . ' z� DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLAi2ATION SFPJADD/REM QO I HEREBV AFFIHM UNDER PENALiY OF PEFiJURV THAT 1 AM EXEMPT fROM THE CAMRAGTORS LI- G$f8�0/C2fp0�L W CENSELAWFORIHEFOLIOWINGREASON(SEC.7031.58U$INE$SANp`PROFESSIDNSCbDEiANVCiTYOR (n , C.) COUNTYYNitCHRE0IJIRESAPERMtTTOCONSTRUCT,ALTER.IMPROyE,DEMOUSH,ORFjEPAIRdNY$TRUG �ll patiol�eck WTURE,PRIOR T�ITS ISSUANCE.AL50 REIXJIRES THE APPL�CANT FOq SUCH PEHMI7 TO FILE A SIGNEO W , .. " � STATEMENT'fHAT HE Oti SHE IS L�CENSEO PURSUANT TO THE PROVISIONS OF hIE CONT�RACTORS'LI� C CENSE LAW(CHAPTER D(COMMENCINO WfTH SECTION 7000)OF pIVISKIN 3 OF THE BU5INESS�A�YD Pq0- u' PooUSpa F FESSIONSCOD�ORTHA7HEORSHEISE7(EMPTTHEREFROMANfJTHEeASISFqqTHEALL�QEDEXE`MP- C�J� . ...., : , iio Z Re-Roof TpN.ANY VIOLATION OF SECTION 7037,3 BV ANY APPLICANT FOR A PERMIT SU&IECTS THE APPLICAN F ACMLPENJLLTYOFNOTMOPETHANFIVEHUNOREODQLtARS(55ooJJi � "���" '"".'`. o ❑I,ASONMEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIR50LECOMPENSATION. ❑ Com111BfCial ' � Z WILL DO THE NfORK.AND THE STRUCTURE IS NOT INTENDED OP OFFERED FOR SALE(SEC.Y044,8U51- ,J NESSAN�PROFESSIONS CODE:TNE CONTRACTORS LICENSE LAW DOES NOT APpIV TO AN OWNER OF � PqOPERTVWF10BU1LDSORIMVROVESTHEREON,ANOWHODO"E.SSUCHWORKHIhISEIFORIi�'RSELFOR � CC THFiOU(iHHISORHEH064NEhiPIOYEE3;PROVIDEDTHATSUCHiFAPROVEMENTSAY�ENbTiNTENDED�OR � QOFFEREDFORSALEIF,FiOWEVERTMEBUILANGORIMPROVEMENTISSOtDWITHINONEVEAHOFCQMPLE ' Z TIpN,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVIN4 THAT HE OR SHE bID NOT BUILD OR . = IMPNOVEFORTHEPURPOSEOFSAL�. �� �" •�"� �� ❑I,A3 OWNER OF THE PPOPEFTY,AM E%CLUSIVELY CqMRACTING WITH LICENSEO CAN7RAC70R5 � TO CONSTRUCTTrIE PHOJECT(SEC.7044,BUSINESS AND PROFESSION5C6DE�-THE�CONTRACTOR$U� VelU8tl0� ADJ.AREA LLl CENSELAWDOESNOTAPPIYiOANOWNEROFAPflOPERNWHOBUILDSORIMPROVESTHEAEON,ANO � WFIOC6NTR11CTSFORSUCHPROJECTSWI7FiACANTRACTOH(S)LJCENSE�PURSUANY70TH�C6NTRAG QUANTITY DESCRIPTION � FEE Y TOiiS UCENSE UWJ. � ' �� � ❑I MI EXEMPT UNDER S�G_ _. B.6 P,C.FOF 7H15 REASON U � � �'�' DATE OWNER � � � � � �Q LICENSED CONTRACTORS DECLARATION W - fL I HEfiEBV AFFIflM UNOER PENALTY OF PEFUUM THAT I AM LICENGEO UNDER PROVISIONS OF CHAPTER � ! ' . - � B(COMMENCINO WITH SECTION i0ao)OF DIVISION 30F THE BUSINESS AND PpOFES51oNS CADE,ANO � ���-� � �-""' MY UCENSE IS M FUIL FORCE AND EFFECT Z �,! � py� LA1 G m 3 X•/!�'�„i4�°L°� �.Pl-��-�' � � t o LICENSE C1A53�y��C_ LIC.NO. �.��'�-"��� �.��. �- V DATE�-�Tj� CONTRACTOH�.(��,,,�,�_�yEq?�' .d � �,.- � � t� WORKERS'COMPENSATION DEGLARATION �� � V � IHEREBYAFFIHMt1�IDERPENALTYOFPERJUFVONEOFTHEFOLIOWINGDECURATIONS: Cf� Z � _INAYEANDWILLN7AINTAINACER[IF!CATEOFCONSENTTOSELFIVSUREFORWORKERS' I =1 � COMPENSATION,ASPROVI�EDBVSECTION370oOFTiELABORCO�E,FORTHEPERFORMANGE i, ��__ OF 7HE WOF1K FOR WHICH THIS PEF�A�T IS ISSt1E�. � O � _iH11VEANDWILIMARJTAINWORKERS'COMPENSAiIONINSURANCE.ASREqU�REDBYSECTION � Q 37DOOF hIE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.MYWO S' MPENSATION�,�,INSVRANQECKRRIERANDPOLICYNUMB�RARE: CONSTRUCT�ON �r� �^v . .. .._ ._....,_ .�"""_....__...._�_�.___...._." j cnRPoea__._ � '" a-- .... �-��In.V e� .. _. . ! � PLAN REVIEW ... .. . Z POLICY NUMBER ' � s–��� • i ELECTE.i4C., � � l � (lHISSECTKNJNE�NOTBECOhFI.ETEDOFhCFERMIT�.SFORONEHUNOREDCIXiMS(SSao)ORLESS} I' PI.UMBING /' � �- � I CEHTIFY THAT IN THE PEHfORMANCE OF TNE WORK FOR WHICH THIS PERMI7 IS ISSUED.I MECfiATTICAL Z (_J SHALLNOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECAM[SUBJEC770 THE � WORKERS'COMPENSATION LAWS OF CALIFOHNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE � Sll&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTIqN37000FYHEtABOR � CADE.I SHALL FOR7H 7H COMPLY WIhI TH0"E PROVIGIONS. ISSUANCE �, Ir � p �ATE:����.�APPIiCANT: ��h.-+ �(' .✓ E." SMIP . W ENERGY P/C J WARNING FAIIUPE?O SECURE WORKERS'COMPENSATION COVSRAGE IS UNLAWFUL, 0 SHAIL BE � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT OOLLARS(i1 a0.o00).IN ADDITION TO THE COST OF COMPENSATION,DAIAAGES AS PROVIDED FOR IN g ¢ SECTION37080FTHELAB0�9CO�E,INTEREST,ANUATTORNEY'SFEES. RETENTIONFEE: �1����a'���.C�_�, ' ' ' 7 oCONSTRUCTION LENDING AGENCY � PRE-ALT FEE: �����,��'`,'��,�_e•,��,,�.�..�r � 1 HEREBV AFFIRM UNDER PENALTV OF PEflJURV hIATTHERE IS ACONSTRUCTION IENDING AGENCY FOR THE PERFORMANCE OF THE WOPK FOR WHICH THIS PEPMIT IS ISSUE�(SEC.308],CIV.C.j. Z W . ::-. ::,..:. :'.-.,. Z LENDER'SNAME � - � � :'��.�:.. � F- LENOER'SADORESS_____ �'"'r . � ICEHTIFYTl1ATIHAYEFEADTHISAPPIICATIONANDSTATETHAiTHEABOVEWFORM0.TIONISCARRECT. TOTAL f EES � - /' �y ��� � 1 AGREETO CAMPLV WITH ALL CITY PNO COUNTY ORDINANCES AND STATE LAWS REIATING TO BUIIAING � � Y� ��! � CONSTRUCTION,Af�HEREBY AUTHORIZE flEPRESENTATNES OF 1NI5 COUNN TO ENTER UPON THE � , ,,, . ' . ., Z ABOVE�MEMIONEDPNOPERTYFORINSPECTIONPURPOSES. COMMENTS O � :� � � a�.-� � 1�� �����;a �"' ' ' � PERMITTEE NAME(PRIN'� Q Cp Vy SI(iNANREOF ERMITTEE DATE � ' ?";5 = RECPT.NO. 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