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HomeMy WebLinkAbout15749 (23) . �C�'-�C _ � ____!� CITY OF DIAMOND BAR �- / DEPARTMENT OF COMMTJ�TY 8�DEVELOPMENT SERVICES �j`2>�'j`�/� 21660 E.Copley Drive Suitc 190 il (909)8603195 Fax(909)861-3117 �� PRESS ��'N�"��Jw BUII.DING PERMIT APPLICATION �%(/ FIRMLY ¢ ADDRESS S I ! / /i !'"1 . �(�� � � �"W. <.:..... ., y JOBSITE � ^- APPLICATION PERMIT�f,'� P/C o y DATE NUMBE # $ ISSUE TYPE OCC APN OT TRACT DATE CONST. GROUP � OWNER �I"�/� 0 ADDRESS !,� L� ' ZONING SETBACKS � CITY ZIP TEL. REART RW � APPUCANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ ADDRESS � CITY ZIR���TEL.` G- PROPOSED USE ~� ^2 �( � � { w ARCH/ENG! �,f G r ���,, DESIGNER NO.DWEL. NO. ,^ NO. � � ADDRESS — UNITS STORIES BEDROOMS � CITY ZIP TEL. � u� DESCRIPTION SQ.FT FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADD/REM WO I HEREBY AFFlRM UNDEF PENALTY OF PERJURY THAT i MI EXEMVT FRON THE CONTRACTORS LF Garage/Carporl CENSEUWFORiHEFOLLOWINGREASON(SEC.7031.5fi11SINESSAN�PPOFES510NSCODEANVCITVOR (n COUNT'WHICHREQUIRESAPERMITTOlbNSTRUCT,AITER.IMPROVE,DEMOLISH,ORqEPAIRANYSTRUG W PdtIO/�eCk W TURE.PRpR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUqi PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF � CEN9EUW�CHAPTER9(COMMENCIN4WITHSECTION70�0)OFDIVISION30FTHEBUSINESSANDPR6 �- PooUSpa FES510NS CODE)OR TFIAT ME OR SHE IS EXEMPT THEREPROM AND iHE BA515 FOR 7HE AllE0E0 E%EMP- TION.ANYYIOLATIDNOFSECTIDN7031.68YANYAPPLICANTFORAPERMITSU&lECTSTHEAPPLICANTTO Z Re-Root �� � ACMIPENALTY DF NOT MORE THAN FIVE HUNORED DOLURS(5500).): A ❑I,ASOMMEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIFSOLECOMPENSATION, ❑ COmm9fCiHl � VIILL DO rFIE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFfERED FOR SALE(SEC.7oaa,BUSF J � NE55 ANO PROFESSIONS CODE:THE CONTPACTORS UCENSE UW�OES NOT APPLV TO AN OWNER OF � � PROVERTV WFIO BUIL➢S OH IMPHOVES THEREON,IWD WHO�OES SUCH WORK HIMSELF OR HERSELF OR � THROUGHNISORHEROWNEMPLOYEES,PROVI�EDTHATSUCHIMPROVEMEMSARENOTINTENOEOOR m 0 OFFEREDFORSPLEIF,HOWEVERTMEBUIl01NGORIMPFOYEMENTIS50LOWITHINONEYEAROFCOMPIE Z TION,THE OWNER�BUIIDER WILL HAVE TME BUR�EN OF PROVING THAT HE OR SHE DI�NOT BUILD OR = IMVflOVE FOR THE PURPOSE OF SFLE). ❑I,AS OWNER OF THE PROPEFiTY,AM E%CLUSIVELY CANTHACTING WITH UCENSE�CONTRACTORS � 70 CONSTRUCT THE PFiWECT(SEC.7064,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V8luation �� eJ��ADJ.AREA Lld CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERYYWH08UIlDSORIAiPRQVESTHEREON.AND ;L y/��p(bNTRACTSFORSUCHPROJECTSWITHACONTRACTOR�5ILICENSEDPUfiSUANTTOTHECONTRAO QUANTITY DESCRIPTION FEE � TORSLICENSELAW.). ❑I AM EXEMPT UNDEFl SEC. B.8 P.C.FOR THIS REASON Q � U � � DA7E OWNER U � W � LICENSED GONTRACTORS DEGLARATION W � I HEFlEBY AFFIHM UNOEP PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINf3 WRH SECTqN 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z MV IICENSE IS IN FV�O�E D EFFECT. m d LICENSECLAS '�LIC.NO. � ���� j V DATE �� CONTRACTOR d W � WOFKERS'COMPENSATION DECLARATION ✓'Z, Q ✓ � I HEREBY AFFIqM UNDEF PENACN OF PERIURY ONE OF THE F9lLOWING DECURATIONS�, Z C� _IH�VEANDWILLMAMTAINACEflTIF�CATEOFCQNSENTTOSELF-INSUpEFOPWORKERS' _ �� COMQENSATION,AS PROV!DED BV SEC710N 37o00F 7HE LABOP CO�E,FOR 7HE PERFORMANCE �U O ORICFORWHICHTHISPERMITISISSUED. � 0 _I HRVEAND WILLMAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REOl11RE0 BY SECTION Q 37000F THE LABOR CODE,FOR THE PERFORMANCE THE WORK FOR WHICH TNIS PERMIT IS Y v �.R O ISSUED.MY WORKERS' MVEN ATION I RAN AfiRIER AND POLICV NUMBERARE: CONSTRUCTION > CARRIER�','��' � PLANREVIEW � ZaOLICVNUMBER— — ____ .—�---�_. .__.._._.___... .. "' . ELECTRIC Q �`- 0 (iHi55El,"i/JNNE�NO78EOJMPLFTEDOFhiEPEFAfftISF�RIXJEHUNDRED00l1AR5(51aD)OqLESS) PLUMBING Z ICERTIFY THAT MTHE PERFORMANCE OFTNElVORK FOq WHICH THIS PERMIT I51551JED,i MECHANICAL (� SHALLNOT EA/PLOYANY PERSON IN ANY MFNNEF SOAS 70 BECOME SUBJECT TO THE � WOPKEHS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THA71F I SHOl1LD BECOME INSPECTION FEE r SUBIECT TOTHE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OFTHE L4BOR � CO�E SHALLFORTHWITHCOMPLYWITHTHOS ROVISION6 � ISSUANCE ,__ � O % p DATEI� �� APPUCANT: �y SMIP __ t J WARNING FAIWRE TO SECURE WORKERS'CAMPENSATIO COVERAGE IS IJNLAWFl1L,AND SHALL BE ENERGY P!C _ ✓ LL SU&IECTANEMPLAVERTOCRIMINALPENALTIESANDpVILFINESUPTOONEHUNORE�THOUSANO ENERGY PERMIT �1 DOLLARS(S10o.000).IN ADOITION TOTHE COST OF COMPENSATION,DAMAGES AS PqOVIDED FOR IN � SECTION37080F'HELABORCO�E,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIRM UNOER PENALT'OF PERJURY THATTHERE IS ACONSTRUCTION LENDMG AGENCY � FOR THE PERFORMANCE OF THE WORK FOP WHICH THIS�ERMIT IS ISSUE6(SEC.309�,CIY.G}. . Z W �Z LENDER'S NAME � F— LENDER'SRDORE55 �^-� W I CEFTIFV THAT I HAVE REA�THISAPPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CARRECT. TOTAL FE ES R. -7 a � I AGREE TO COMPLV WITH ALL CITV AN�CAl1NTV ORDINANCES AND STATE LAWS RELATING TO 9U�LOWG � � CANSTRUCTION,pND HEFEBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTV TO ENTER UPON THE - Z ABOVE-MENT NEO PROP OP INSPECTION�URPOSES. COMMENTS � J � � PERMITTE�E�T) . �� J M /� �/J � ` �-' /1/�,y-�= ��lC/� �� ,.�- � SIGNATUREOFPEHMITTEE �A7E � RECPT.NO. 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