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HomeMy WebLinkAbout15455 (23) � � �,S CITY OF DIAMOND BAR �� rc DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 (909)860-3195 Fau(909)861-3117 PRES$ 9�' BUI�:DIriG PERMIT A�'PLICATION , , ., y FIRMLY .. . .. .., . .�., y JOBSITE � .�� � �i�„,� ��� � APPLICRTIO � (�� PERMIT $/�,� ,�r�' ` P/C o ADDRESS � �� r3'� � DATE � v NUMBER "-9' �-�'� # � V ISSUE �' TYPE OCC' APN LOT TRACT DA7E � 'n CONST. GROUP t'�j OWNER:,.. ., �,,� <.�'� ;. o«�.�;-2, �` ADDRESS " '"'"'� `���fi-` ZONING SETBACKS � CITY �*�':���..,✓� P-?� IP J; ..�,. EL � i. .r.�-t�,�;;,�.:- FRONT RW C APPLICANT ✓' ` � ' TEI. N �',� �- , REAR ❑ � �� � SIDE/SIDE STREET RW C { ;•.��.�s ? SIDE C CONTRACTOR :i�"5 ; `� 1 V.� r ti,i '�;'"- q� ADDRESS� ` � e "' PROPOSED USE c� CITY ZIP TEL. ��-.� o ARCH/ENG! � DESIGNER NO.DWEL. NO. NO. AODRESS UNITS STORIES BEDROOMS � CIN ZIP___ TEL. cn ce� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLAFATION SFR/ADDlREM WO I HEREBY AFFIRM UNDER PENALTY OF PEFiJURY THAT I AM EXEMPT FROM THE CONTRACTOqS LI� G8fa(JB/C.fltp012 CENSELAWFORTHEFOILOWINGREASON(SEC.7031.58USWESSANDPROFESSIONSCODE:ANYCITYOF (n C� CqUNTYWHICMREOUIRESAPERMtTTOCONSTRUCT,AITER,IMPROVE,DEMOLtSH.ORREPqIRANYS�RUP W patio/Deck Z TURF.PRIOR TO ITS{SSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� ��� STpTEMENT THAT HE OH SHE IS LICENSEO PURSUANT TO THE PHOVISIONS OF THE PANTRACTORS LI� W � CENSE LAW(CHAPTER 9(COMMENCINd WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- �'1' PooLlSpa FESSIONSCODE)OHTFUTHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEG6DEXEMP� � TION.ANYVIOLATIONOFSECTION7o3i.5BYANYAPPUCANTKORAPERMITSUBJECTSTHEAPPIICANTTO z Re•Root �„� ACIVIIPENAI.TYOFNOTMOREiHANFIVEHUNDAEDDOLLARS(i5o0}): ' � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESAS7HEIRSOLECAMPENSATpN, � Commercial - WIU.�O THE WORIC,RJD THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7046,BUSI- J N NE5S AND PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW�OES NOTAPPLY TO AN bWNEq OF � PRbPERTY NIFIO HUILDS OR IMPpOVES THEREON,AND WHO DOES SIJCH WOPK FIIMSELF OR NERSELF OR � THROUCiHHISORHEROWNEMPLAVEES,PHOVIDEDTHATSUCHMPpOVEMENTSARENOTMTENDEDOR m QOFFERfDFORSAIEIf,HOWEVER7HE8U0.,DWGORIMPROVEMEN115SOLDWITHINONEYEAROFCAIAP�E- z �710N,THE OWNEp-BNLDER WILL HAVE THE BURDEN OF PfIbVING TFIAT HE OR SNE DID NOT�BUILD OR = IMPEIOVEfORTHEPURPOSEOFSALE). �� � � �� uj ❑i,ASOWNEiiOFTHEPROPERTY,AME%IX.USIVE4YCONTflACTINGWITHUCENSEDCONiRACTORS Q[ TO�JDIVSTRUGT THE PFOJECT(SEC.7044,9USiNE55 AND PflOFE55iON5 CODE:THE CONTqACTORS 1.1- VHIU8PIIX1 ADJ.AREA LLI CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPEqTYWH08U1LD50RIMPROVES7HEREON.AND � WFiOCONfRACTSFORSUCHPROJECTSWITiACONfRACTOR(SjLICENSEDPUH5U4tN1'TOTHECONTM0. QIJANTITY DESCNIPTION FEE � TOPoS UCENSE UW.). � O I AM E%EMPT UTAER S�Q_ B.fl P.C.FOR THIS REASON Q '� U W � DATE OWNER � Z W � LICENSED GONTRAGTORS DECiARATiON W �. I HEREBV AFFIRAI UN�ER PENALTY Of PERJURY THAT I AM LICENS[D UNOER PROVISIONS OF CHAPTER g� � D(COMMENCINCi WITH SECTION 7000)OF DIVISIDN a OFTHE BUSINESS ANO PS1oFESSIONS CODE,AND Z 4r� �Y 97 �. X MY UCENSE IS IN FULL FORCE AND EFFECT. � � LICENSE CLASS s^'- �'� .^ LIC.NO. G���(-� Y7 � M�- � �/ J �j DATE �_/�T=i.��%' ^ CONTRAGTOH�� Ll. W � WORKERS'COMPENSATION DECLARA710N a � I HEHEBV AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING OECLARATIONS: z � � `I HAVElJJD WILL MAINTAIN A CER7IFICATE OF CONSENT TO SELFlNSUpE FpR NbRKERS' _ � � � � COMPEN3ATION,ASPROVI�EDBYSECTION37o00FTHElABURCODE,FORTHEPEFFORMANCE 'U OFIFIE WORK FOR INNICH THIS PEflMIT IS ISSUED. � W � I HAVE ANO WILL MAINTAIN WORKERS'COMVENSATION INSURANCE,AS REQUIRED BY SECTION Q 370o OF THE LABOfl CODE.FOR T1E PERFOPMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED.MY WORKE�AS'c/�MPENSATION INSUPANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION jCnr3RIER 7(,�> � "'" d'k PLAN AEVIEW � POIICYNUMBER Ty�./_���;. P_�_ ELECTRIC Q 0 (n�xs[cncr�r��uoreemu,ri�ooFn+eaEw.mrsFoaotaE;s.m[x�ooca�nnsgiw)oa�Ess�. PLUMBING . � �� ,. w �{ Z 1 CERTIFVTFIAT IN h1E?EFFOPMANCE OF THE WORK FOR W!i1CH THIS PCRMiT IS ISSUED,i MECHANICAL _�.�! Otl CyS SHALL NOT EMPIOY ANY PEASON IN ANY MANNER SOAS YO BECOME SUBJECT TO THE ����`j„�,d� � WORKERS'COMPENSA710NIAWSOPCALIFORNIA,FN�AGRFETHATIFISHOULDBECOME INSPECTIONFEE SUBJEC7 TO THE WdRKERS'COMPENSATION PROVISIONS OF SECTION 37Co OF iHE LABOR �^" ,/') � CODE,ISHAL4.FORTHWI7HCOMPLYWITHTHOSB'PROV IONS. ISSUANCE l..,seF4 �"��Y � p DATE: `�'`� —��eAPPLIGANT:y_ � � --}— SMIP __�11 Ep � � 4 J WARNING:FAILURETO SECJRE WORKERS'COMPENSATION COVERA�E I�Fl1L,AN�LBE ENERGY P!C ��, Y �A� � SU9JECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDflED7HOUSANO ENERGYPERMIT"'� '"�' y�+ � �yyg ��� DOLURS(5700.000).IN ADOITION TO THE COSTOF COMPEkSATION,DAMA6E5 AS PROVIDED FOR IN ,J (� -��;9 e � SECT�ON3708OFTHELA80RCODE,INTERESLANDATTORNEYSFEES. F">3y}�� RETENTION FEE:y���w�'6��� OCONSTRUCTION LENDING AGENCY PRE-Al7 FEE: � t HEREBV AFFIRM UNDER PENALTV OF PERJURY iHATTHEFE IS ACONSTAUCTION LENDING AGENCY ' FOR THE PERFORMN�CE OF THE WORK FOR WHICN THIS PERMIT IS ISSUED�SEC.308n,CIV.C.). . � Z W � LEN�ER'S NAME 1— LEN�ER'SADDflE55 /y � TOTAL FEES (�� w I CERTIFV THAT I HAVE READ THIS APPUCA?ION AND STATETHATt'HE ABOVE INFORMATION IS CARRECT. ` 9�� � I AOREE TO CAMPLY WITH ALL CITY AN�COUNTV ORDINANCESAN�STATE LAWS RELATINO TO BUILOINQ . �„� / � CANSTRUCTION,ANDHEREBVAUTHORIZEPEPRESENTATIVESOFTHISCOUNT'TOENTEflUPONTFiE � Z ABOVE•MENTIONED PROtPEHTY FOfl MSPECTION PURPOSES. COMMENTS ' � �����' �' �l�c`��� � m PEHMITTEE NAAIE(PRl )•..--�•''��^J�^'"'_� r (/� ..Y'.�...`_._.`� s.�' C �-'��^'_. �w...(�"-�� - � � vj SIC:NATURE�OFPEflMffTEE ,�� ��-- �ATE ' = RECPT.NO. 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