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HomeMy WebLinkAbout10318 i� �.. CITY OF DIAMOND BAR COMMUNTTY DEVELOPSvIENT DEPARTIvIENT � ;,.� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Faa(909)861-3117 �'""' BUILDING PERMTT APPLICATION FIRMLY .., N JOBSITE " � a LICATI4N PERMIT P/C o ADDRESS � E_ NUMBER �� # c� SUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER " ADDRESS � d ' ZONING SEfBACKS g CITY� ZIP��' � • � TEL. y' FRONT RW ❑ APPLI ANT �� TEL. REAR ❑ SIDE/SIDE STREET RW C � CONTRACTOR ° --c�sa�"!^'d SIDE ❑ � ADDRESS PROPOSED USE � CITY �' ZIP� TEL. '�73 T.4'/S�'1 o ARCH/E G/ _ iz DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. c�n DESCRIPTION SQ.FT. FACTOR PSF ADJ_AREANALUATION p� OWNER-BL'ILDER DECLARATION SFR/ADO/REM O � I HEREBY AFFIqM UNDEP PENALTV OF PERJURV THAT I AM E%EMPT FAOM THE CONTRACTORS ll- (}8f8gB/C3l�10fI W CENSEUWFORTHEFOLLOWINGHEASON(SECJo3L6BU51NESSANDPROFESSIONSCODE:ANYCITYOR (n U CWNNWFiICHRE�UIRESAPERMITTOCONSTRUCT,QTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W PdfiO)DOCk TURE.PRIOR TO ITS ISSUANCE,ALSO HEOUIRES THE APPUCANT FOR SUCH'PERMIT TO FILE A SIGNED � STATEMENT TFMY ME OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTFACTORS LI- � � CENSE LAW(CHAPTER B(COMMENCIN(i WITH SECTION 7000)OF piV1510N 30F'THp BU51NE58 AND'PR0. POOUSpB FESSIONSCADE)ORTHATHEORSHEISEXEMPTTHEREFROMAND7HEBASISFORTHEALLE�EDEXEMP� (,� � � TION.ANYVIOLATIOMOFSECTION7031.59YANVAPPLICANTFORAPERAlITSUBJECTSTHEAPPLICANTTO Z Re-Roo1 ACIVILPENALTYOFNOTMOHETHANFIVEHUNOPEDOOILARST95oo�.�:�-�--��-�- � - � ❑I,ASOWNEROFTHEPROPER7Y,OHMVEMPLOYEESWITHWA�ESASTHEIRSOLECOMPENSATION, Q Z Gommercial WILL DO THE WORK,AND THE SiRUCTUFE IS NOT INTENDEO di OPFERED FOR SALE(SEC.]0�4,BUSI• J � NESS ANO PROFESSIONS CODE;7HE CONTRACTORS LICENSE L'AW�OES NOT APPLYTO AN OWNER OF j PFOPERTY WHO BUILDS OR IMPROVES THEqEON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF Oq � THROUGH H�S OR HEA ONRJ EMPLOYEES,PPOVIDEDTHATSUCH IMPROVEMEN7SARE NOT INTENDED OR m � OfFERE�WHSPLEIRHOWEVER,iHEBUILDINGORIMPROVEMENTISSOIAWITHINONEYEApOFCO�APIE� Z TION,THE OWNER-9UIl�EN WILL HAVE THE BUROEN OF PROVING THAT HE OP SHE DID NbT BN(D OR � IMPROVEFONTF�PURPOSEOFSAIE�. W ❑I,ASOWNEROF7HEPROPERiV,AMEXCLUSIVELYCONTRACTINOWITHLICENSE�CONTRACTOqS [,� TO CONSTRUCT TME PRQIECT(SEC.7044,BUSINESS AND PROFE5310N3 CODE:'HE CONTRAQTOR3 U� V0N8I1011 ADJ.AREA W CENSELAWOOESNOTAPPLY?OANOWNEROFAPROPERTYWH09UI1.D50RIMPROVES7HEREON,ANO � WHOCONTRACTSfORSUCNPRQIECTSWYfHACANTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE y TONS LICENSE LAW.). } � /+ � ydQAM EXEMPT UNDER SEC. B.E P.C,FOR THIS REASON 4 � l I L�'�'��-�(,.� 9 �� ,�,1, '�� U LL � DATE �`+ gi OWNER U 0 W ��[ LICENSED CONTRACTORS DECL4RATION W � "� � CL 1 HEREBVAFFIRAI UNOEH PENALTV OF PERlURY THAT I AM LICENSED UNDEN PROVISIONS pF CHAPTER � ''" - ,� ` ' ' � D�COMMENCINGWITHSECTION700o)OFDIVISION30FTHEBUSINESSANDPROFESSIONS(�DE,AND Z ' MY GCENSE IS IN FULL FORCE AND EFFEC7. lL �j � t�� m � LICENSE,y�C�LASS �'�`� LIC.NO. � _ � ~ DATE=/"Z��'J CONTRACTOR � � d - W � :.�. i F ,x, :�:-;` , � WORKERS'COMPENSATION DECLARATION Q �s.,��' � � i HEREBYAFFIRM UNUER PENALTY OF PEFUURY ONE OFTHE FOLLAWING DECLAPATIONS: Z � � _IHpVEANOWILLMAIN7AINACERTIFICATEDfCAN5EN7T03ELF•INSUREfORWORKEq3' _ COMPENSATION,AS PFOVIDEO BY SECTION 37oa OFTHE IABOR COOE,FOF THE PERWRMMICE W Q OF TNE WOPK iOR WHICH THIS PERMIT IS ISSUED. � � _I HAVE AND WILI MAIN7AIN WORKERS'CAMPENSATION INSURANCE,AS RE�UIHED BY SECTION QQ 37ao OF THE LABOR CODE,FOR THE PERFOHMANCE OF THE WORK WRriHICH 7HIS PERMIT IS ISSUED.MV W9flKERS'COMPENSATION INSURANCE CARRIER ANO POLICY NUMBERARE: CONSTRUCTION J j CARRIER PLAN REVIEW ZPOLICYNUMBER ELECTRIC >Z� Q � (MISSECIIONNE�NOTBENMH.EiEDOF7HEPERMTISFORONEMNDREDDOl1APS�E100�ORLESS). PLUMBING y Z 1 CEFTIFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED,I MECHANICAL 1'� L�^G (�j SHALL NOT EMPLOV ANV PERSON IN ANY MANNER SOAS TO BECOME&UBJECT TO'tNE � WORKER3'COMPENBATION LAWS OF CALIFORNtA,ANO AOREE THdff i SHOULO BECOME INSPECTION FEE - � SUBJEC7TOTHEWORKEflS'CAMPENSATIONPROVISION50FSECTION37ooOFTHELABOR = CO�E,I SHALL FORTHWITH COMPLV WITN 7HOSE PROVISIONS. �SSUANCE o� � SMIP p DATE: APPLICANL J WIIRNINGFAILUflETOSECUREWORKERS'COMPENSATIONCOVEHAGEISUNUIWFUL,ANDSHALIBE ENERGYP/C LL SU&IECT RN EMPLOYER TO CHIMINAL GENALTIES AND CIVIL FINES UP TOONE HUNDREDT410USAND ENER6Y PERMIT ODL1AFiS(5100.000).IN A[/01710N TO 7HE COST OF COMPENSATION,UAMAGES AS PROVIDEO FOR IN � SECTIDN 37oe OFTHE LABOH COOE,INTEHEST,AND ATTORNEV'S FEES. RETENTION FEE: ' OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBYAFFIRM UNOFA VENALTV OF PERJURY THAT THERE IS ACONSTRUCTION LENDIN6 AGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.�. W � LENDEiNSNAME � " 1— LEN�ER'SADDRE55 � ICERTIFVTHATIHAVEREADTHISAPPUCATIONANOSTATETHATTHEABOVEMFORMATIONISCORRECT. TOTAL FEES � ������� Q I A6REE TO COMPLY WITH ALL CITYAND COUNTY OROINANCES AN�STATE UWS pELATING TO BUILDING �� �� .�, � CANSTRUCTION,pNDHEHEBYAUTHORIZEREPRESENTATNESOF7H15COUNTVTOENTERUPONTHE J���� ��,/������f�J�� // .� , ABOVE-M NTIONE�PROPERTV FOR INSPECTION PURPOSES. COMMENTS (�/��� � /e / / ..�//'u 11'� O v ��_ `-_ m PERMI AKIE(PF�NT) - � - � �' p: 4 C�_ �,.2-3-5.� ' ; � , = SIGNANPE OF PERAIITTEE DATE 7�f '��� �,s� 3 RECPT.NO.� ��Z- PAID BY I`� .'"�`yl�Li�DA71U��� � ��. �� ~ WHITE—Department Copy,YEILOW—Finance Copy,PINK—Assesso�Copy,GOLDENROD—Flie Copy,GREEN—Applicant's Copy `' _°r�' ,:�. ;., ,. . . 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