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HomeMy WebLinkAbout13689 (14) „.._.. �� CITY OF DIAMOND BAR �� DEPARTMBNT OF COMMUNITY&D�VELOPMENT SERVICES � : _� 21660 E.Copley Drive Suite 190 PRESS »� , (909)860-3195 Fax(909)861-3ll� , Bun,Dttvc rE�rr�r�rt.icaTTorr �_ , , ,., ,� FIRMLY , _ . .. . ,.�,.. .� �. �. .;, oJOBSITE �Q,��� � (,�. �/���G� fi S '�` DATE CATIOaZ/�s�/R,� ., NUMBER ���C/ #/ /��� a ADDRESS k r r c�i r v� ISSUEi� r�-TYPE OCC �,:� APN LOT RACT DA7E CONST. GROUP p OWNER ��Q � UES�' ApDR S ZONING SETBACKS W C{TY � � ZIP r� T- � FRONT RW ❑ � APPLICA ��r'"�_�f�� TEL���^� REAR ❑ � � SIDE/SIDE STREEf RW J a� CONTRACTO ' CJ ��� 1 a SIDE ❑ p� ADDRE S ”' e{' PROPOSED USE j���I�I�N�/M�' !.._ !/Q CITY r ZIP � �TEL. _ _ � w ARCWENG/ .� ���y�'!�p'�/ ��z,, DESIGNER (Ir� �- .L� �G�t... �"y ADDAESS ^ - ,[ NO,DWEL. NO. NO. = CITY � ZIP T�L. UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUII.DE DECLARATION 5FRlADD/REM p 1 HER6@V AFFIqM UNDER PENALTY OF PERJURY THR71 AM EXEMPT FROM THE CON?RACTORS LI- � Gafa�B/Cafpoff � LLI CENSEL4WWRTHEFOLLOV/INGHEASON(SEG.70.3�.58USINESSANOPPOFESSIONSCbDE:AtJYCITYOfl ' COUNTYWHICHREWIRESAPERMITTOCONSTRUCT,ALTEP,IMPROVE,DEMOLISN,OR6IE,PAIRANYS7RUG W P2fio/DBCk 'f�PE,PRIOH TO ITS ISSUMJCE.A50 REWIHES TME APPLICANT FOR SUCM PEFMITTO FILE A'51GNE0 w STATEMENT 7HAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVIS�ONS OFYHE CONTRACTOpS LI� � � CENSEL0.W(CHAPTERe(COMMENCINOW�THSECfION7oavfOFI�IVISION34FTHE805WE$$dNd'PRO� �'�' PoOUSpa ' FESSIONS CODE)OR THA1 HE OR SHE IS EXEMPT THEREFROMAN�THE BASIS FORTHE ALLEGEB�EREMP- TIDN.ANYVIOL,ATIDNOFSEGTION7031.6BYANYAPPLICANTFORAPERMITSU&IECYSTfiERPVLiCAIJTTO Z Rp-ROOf I � ACtVIL PENALTY OF NOT MORE TiAN FIVE HUNOREO DpLUqS(55oa).�: � �� � � pI,ASOWNEROFTHEPROPERN.ORAAVEMPLOYEESWITHbM1WGESASiHEIRSOLECOMPEP�SA7ION, � Commercial � � WILL DO THE WORIt,AND THE 3TRUCTl1RE IS NOT INTENDEp OR OFFEFm FOA SAI.E(SEC.70d4.'BUSI- �1 � NESSANO PROFESSIONS COOE:THE CONTRACTORS I.ICENSfi LAW DOES N�7 A7PLY TO AN OWNER OF �. � PHOPER4YYNiOBU1L030RiMPROVESTHEFEpN,ANDWHOdO'eSSUCHWORKHIMSF.I..F�OpHER9ElFOA ��!� � THRIXJOHHISOpHEROWNEMPLO�EES,PqOVID�THATSUCNIpAPpOVEIAENTSApENOTINT�NpE00R � 0 OFFEREDFORSALEIF,HOWEYER,TFIEBUIID!NGORIMPRDVEiAENYlSSOLDWITHINONEYEAiiOFCb'K1PLE- Z �TWN,YHE OWNER-BUILDER WILL HAVE riiE BURDEN OF PRbVINq THAT HE OR SHE OID NOT-9UI4b OR IMPqOYEFORTHEPURPO5EOF5ALKl. � ' �=y,y O�,/SOVdNEROFTNEPROYEIZTV,AMEXCLUSiVELVCAN7RACTiNGWI7HUCENSEDCOA7q:4C70RS ,,,,,r-� L.�iJ CEk ENUWDOESNOTA�APLYTOANONRJEROFA RO ERT'/WHOBJ�0.WOR MPiiWES HE EON,AN� �'aluation�Q�O ADJ.AREA � NAiqCONTflAC7SFORSU[:FIPROJECTSWITkACONTitACTJRfS)LICENSEDPURSUANTTO7HECfStVTFAG - QUANTITY DESCRIPTION FEE - � TOqSLICENSEUWJ. o p IAM EIfQAPTUNDER SEC. B.d P.C.FOR TNIS REA50N � � � � — r� �a.��.� , � DATE OVlNER 6" U f°'�o LICENSED CON7RACTORS DECLAFATION � � {..i _._ ,^t�. ,"„ � � � IHERE6YAFFIRMUNOERPENALTYOFPERJURYTHATIqMLICENSEOUNDERPROVIS�ON50FCFIAPTER � ��,,,d�'� '� E'"; '.:",',.�;;p�.;„� � •�CqMMENCUJGWITHSECTION7000)OFDIV�SION30FTHEBUSMESSANDPROFESSIONSCO�E;AN� !G MY IICENSE IS IN FIAI FOACEANU EFFECt �m r 3 k��� �r LLI � LIC[NSE CLASS^_, � LIC.NO.� �' � � � - :� . V DATE .��f.�"�r�_._.__ CONTR4CTOR� n- . W � WORKERS'COMPENSATION DECLARATIUN -� d � I HEREBY AFFIRM UNDEii PENPLiYOF PERII+RY ONE OFTHE=OLLOWING DECLARATIDNS: � � -y Z � �y„��VEAMDWII_LMAINTAMACERTIFlCATEOFCONSENT?OSECF-INSIIHEFOfiWORKERS' _ COMPEfdSAT�ON,A5PR0VN]EDBYSEC710N37ooOFTHELRBORCOpE,FOFl7NEPERFORMANCE 9 'U �OF4HE K'ORK FOR WHICHIHIS PERMIT IS ISSUED. � � �,I HAVEPT�ID WILL MAWTAIN WORKERS'COMPENSATIOfJ INSURANCE,AS R'cdUiREO BY SECTION �' 6 p�j 3�OOOFTHE LABOR CODE,FOR'fHE PERFORMANCE OF THE WORK FOR WHICH iHIS PEPMIT 15 0 p���. ISSUE�.MY WORKERS'CnMVENSATION INSUFANCE CARRIER APdD POLICV NUhieER ARE: CONSTRUCTION .__ __ .._ .._....___... . j 'cnaR1ER! ' ' __ _._'_—_` REVIEW __�� , _ �-'—' ZPOLICY NUMBER ELECTRIC � Q � (fFiISSECi'N7NNE�NOTBE�LETE�OFhiEPEPAtlT6FORONEFILT�iFD00Lll�P5(E100)ORLESS) PLUMBING � ICERTIF/THATINTHEPEftFQRMANCEOFTHEWORKFORWHICHTHISPEtiP.1�TISISSUED,I MECHAI�l�CAL Z (,�} SHALL NOT EMP�OY ANY PERSON IN ANY MANNER 50 AS TO BECAME SUBJECT'O THE � WORKEFS'COMPENSA710N1AW50FCAlIFOqNIAANDAGREE7HATIFISHOULDBECOME IPJS FEE 'p�O SUBJECTTO THE VlORKERS'COMPENSATIO�U PROVISIONS OF�ECTION 370a UF THE LA60R 4 CADE,I SHALL FORTHWITH COMPLV WITH THOSE P O��V,,I�SIO,rN°�S!. � SUANCE �,� � � DATE:�� APPLICAfYf: ___--Ir,A[7�'��'^'`�"�" . .. - � a—r�—yJ r-�---e—..:. , { � WARNING:FAILURE TO SECURE WORKERS COMPENSATpN COVERAGE IS UNtAWFUL AND SHALL BE ENERGY P/C W SU&IECTANEMPLOYERTOCRIMWALPENACf1E5ANDCIVLL.FINESUPTOONEHUNDF�DYHOU�A�D'�� ' �� ENERGYPERMIT DOLLAPS(t1aD,oaO),IN ADDITIQN TO THE C05TOF COMPENSA7ION,DAMAGE5,95 pkiOVlpE�FDR'IN � SECTIDN 87080F THE LA90R CODE.�NTEREST,ANDATTORNEV'S,FEES. � - `"'� RETENTION FEE: �J �p�' r�>„��o ,a CONSTRUCTION L�NDING A�ETJC'V �' , PRE-AL7 F E:`��� t,d,,�ry..�� L�r� IHEREBYAFFIRMUNDERpENALTYOFPENURYTHAT?HEREISACONSTPUCTIONtEN�INGAGENCV � L FOR THE PEfl W RMANGE OF 7HE WORK FOR WHICH h115 PERMIT IS ISSUED(SEC.3oB�,CIV.C.). � W ����i �Z LENDER'S NM/E_� _— { �F— LENDEH'SAODRE55 ��w IAGpE6T0„COMPIVVWTHAALLCITYANDCCO�VORD7NANCESANOSTA ELAIW RELATWG'BUIRDING ��L FEES , ' � CANSTRUCTION,ANDMEREBVAUTHOPIZEREPPESENTATIYESOFTMISCOUNTVTOEYJiEflUPONTHE- Z ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. 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