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HomeMy WebLinkAbout13134 (16) , . CITY OF DIAMOND BAR �� ��-��-� DEPARTMENT OF COMMUNITY&DEVELOP�NT SERVICES � 21660 E.Copley Drive Suife 1� Y ,; {909)860-3195 Fu�(909)$613117 PR $ ... ,.:, s:t ::, u� �$ •�' BiJII.DIN(�P�R1�1IT�i1yl'LICA'�'IOI� � " . " '" FIRMLY . . . � - .,..�,Y.VA.SIt iar.4�.- . , �. . .�..,.,, . .:.. .. .. ..,. , � JOBSITE p /� p�p ,f� arr�i.4.: r w,�,;ne�, w- �r;- ....F�. ,..- ,�r� �r�wk:,.4,e, o ADDRESS�-/ �'/ /7�G ���'` ��� APPLiCA'TIQN � PEI��iAI�'� ��I P/C DATE NUMBER # � APN _,J_OT TRACT �SSUE /'�j� TYPE OCC DATE„�"�B����"T,�CONST. GROUP p OWNER p ADDRE ZONING SETBACKS � ClTY ZIP TEL. �i � REOART RW ❑ APPLIGAN7 TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR " SIDE ❑ � ADDRES$ '" pROPOSED USE_ o cirv �� 21P TEL. ow ARCH/ENG/ W DESIGNER , ., NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP 7EL. � cr� - DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � OWNER-BUIIAERDECLARATION .. �� � SFR/ADDIREM O I HEREBY AFFRM UNDEP PENALTY OF PERJURY THAT I AM EXEMPT FfiOM THE CONTRACTORS LI- Gd��9B/COtPOh W CENSEU1WfORTHEFOLLOWINOFEASON�SECJo3L68051NES5ANDPROFES510NSCODE:ANVCI7YOR (n C� COUNTYWHICHREOIJIRESAPERMITTOCONSiAUCT,ALTER,IMPROYE,OEMOLISH,ORREPAIRANYSTRUG w patio/DCCk z TUPE.PRIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APP�ICANT FqR SUCH PER6AIT TO"FILE A SIGNED - w STATEMENT 1HAT HE OR SHE IS LICENSED PURSUANT TO?IYE CFOVISIONS OF THE CONTRACTORSLI- W � CENSE t,AW(CHAPTER 8(COMMENCINQ WITH SECTION 7000)OF pIVISION a OF THE BU81NES5 AN�PRO- u' POOUSPO FESSIONSCODE)ORTHATHEORSHEISEXEMP77HEftEFAOMAN�THE80.SISFOhTHEALLEGEDE%EMR (� U TION.ANVVIOLATIONOFSECTION7o31.sBVANVAPPLICANTfORhPEPMITSUBJECTSTHEAPPLiCqNTTO Z Re-Roof � ACML PENALTV OF NOT MORE THAN FNE HUN�RED OOLI.HRS�2500):): - ' - ' ''''' �" � ❑I,MSOWNEpOFTHEPROPERTV,ORMYEMPLOYEE$WI7HWAGESAS'THEIRSOLECOMP[PISATION, CommefCiai - WILL W THE WORK,AtJD THESTRUCTURE IS NOT INTENOED OR OFFERED FOR SALE ISEd.70�4.91151- J � NESS AlJD PROFESSIONS CODE:7HE CANTRACTORS UC�NSE LAW DOES No7 APPLY TO AN oWNER oF � PflOPEfliY VMO 9UILD5 Op IMPfiOVES THEREIXV.AND WHO OOES SUCH WORK HIMSELF OR FIEflSELK OH � THF10U4HHISORHEHOWNEMPCOVEES,PPOVIDEOTHATBUCHIMPROVEMENTSARENOTINTENDEOOR m � OFFERFDWRSALEIF,HOWEVERTMEBUIIDINGORIMPROVEMEN7ISSOLDWITHINONEYEAROFCA61pCE- �, iION,THE OWNER�OUILDER WILL HAVE THE BUFgIEN OF PpOViNG THAT HE OR Sfi£'DID NOT 9UIL0 OR � IMPHOVEFOHTNEPI/RPdSEOFSALE). � . . ..' !: ..:..,. �' .,...,. ❑I,A9 OWNER OF THE PROPERTY,AM EXCLUSNE�Y CqNTRACTIN6 NATH LICENSED CQNTflACTORS � YO CONSTRUCT THE PRO:IECT(SEC.1o44,BUSINESS ANq PpOFESSIONS��OE�7HE CONYqAQYDRS U- Valu8lion^, ADJ.AREA W CEN9ELAWDOESNOTAPPLYTOANOWNEROFAPROPEqTYWHOBUItD30RIMPflOVESYHEREON,AND Z NMOCONTH0.CT'SFORSUCHPRQIEC7SWITHACONTRACTOR�S)410ENSmPUpSUANTTOTHECbNTi1AG QUANTITY DESCRIPTION FEE x TORS UCENSE LAW.). . . � �IAMEXEMPTUNDERSEC. B.BP.C.FpRTNI5RFA50N Q � U � � DATE OWNER _____ __. U W� �+Q �� LICENSED CONTRACTORS DECt,ARATION w, Lr I HEREBY iIFFIRM UNOER PENAL7Y OF PERJURY THqT I AM LICENSEO UN�ER PPOVISIONS OG CMAPTEN � d, 9(COMMENCIN(i WITH SECTION 1000)OF 014ISION 30F THE 9USMESS AND PROFESStONS CADE,ANO Z � MY UCENSE IS�I FLLL FORCEA EFFECT. /�y�: ^/ m O LICENSE CLA55_.+��q`/ /}� LIG.ND. - �� I ����� � � DATE �-'�nws-_-�"! . � ��r-f..�C'""' ... J V CONTRACTOR 0-, � � � WORKEFiS'COMPENSATION DECLARATION Q � �HEiiEBV AFFIRM 11P1�ER PENALTY OF GEFUURY ONE OF THE FOl40WiNG�ECLANATIONS: Z � _.IHAVEAN�WILLMAINTAINACERTIFICAYEOFCANSENT70SELF�INSUREFORWORKERS' _ — i CAl1PENSATION.ASPROVIDE�BYSECTION37000FTHEI.A80RCODE.FORTHEPERFORMANCE CJ � /OF hiE WpRK FOR WHICH THIS PERM17 IS ISSUED. � W � �� I HNVEANO WILL MAMTAIN�NOflNERS'COMPENSATION In'SURANCE AS REQUIREp HY SECTION Q37000FTHELABORCOpE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERM1T15 J ISSUED.RIYWORKERS' PE SATIONINSU�IANC�C FlRIERANDPOUCYNUMBERARE: CONSTRUCTION ' �rt'nl!S .. .,., .....�..,,..-.- ..-.........4.....,, _.._.._....... . � CARRIER 4�Y�'r �. pLAN REVIEW� � � � - � � � � � � � POLICYNUMBER � ELEC7R�C Z -- g ��ssEcr�N�s�raT�ar�rEooFn�aEwarr�swFlavEHuwaE000u.aas�s�oo�or3�ss� PLUMBMG _�� G w Z I CEflTIFY TT1AT IN THE PERFpPMANCE OF THE WORK FOR WHICH TNIS PERMIT IS ISSUEC,I MECHANICAL r,m�. C:$ SHALL NOT EMCLOV ANV OEqSON IN ANY MANNER SOAS TO BECOME SUBlECTTO THE � WORKERS'COMPENSATIONL,AWSOFCqLIFOPNIA,ANDAGRFETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSA71ONPROVISIONSOFSECT10N37900FTNEIABOR � C�E,ISH F.qHiHWITHCOMPLYWITHT O PROVI51 s. ISSUANCE ,_ C 6 0,� �_�~� O ;J � p DATE;��`� APPLICANT: � SMIP ('� � v�M J WAflNING:FAILURE TO SECURE WORKERS'COMPENSATION CCVERAGE IS UNLIWFUL,AND SHALL BE ENERGY P/C �-�����w�ka.l=� '.sy� LL SU&IECTANEMPLOVERTOCRIMINALPENALTIESAN�CIVIIFINESUPTOONENUNDREDTHOlISAND }i.� �� DOLLARS(Stoo,a00),IN ADDITION TO THE COST OF COMPENSATIOP3,DAMAGES AS PROVIDE�FOq IN ENERGY PERMIT J SECTbN 3�oe OF THE LA80H COGE,INYERES7,AN�ATTORNEY'S FEES. �f6'�,�C +� W RETENTION FEE: ���.��-��� � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE; O __..__. � IHEREBYAFFIRMUNDERPENALTVOFPER.IURVTHATTHEftEISACONSTPUCTIONLENDINGAGENCY - - - ' - - '- � FOR THE PERFORMANCE OFTNE WORK FOR WHICH THIS PERMIT IS ISSUEP(SEC.3097,CIV.C.). - -�� . . ��. � , � . . . . . .....,. , W - � LENDERSNAME F ��� �� � - _ F— LENDER'SADDRESS /{, � .�, c ' , �'7_,�:.,.;y. (�f�.:: ,,... ICEFITIFYTHATIHAVEREADTNISAPPLICATIONAN�STATETHATTHEABOV�INFORMATIONISCORRECT. TOTALF�CS �� � I AGREE TO CAMPLY WRH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATMG TO BUILDING `-e � CONSTRUCTION.AN�HEREBYAUTHORIZEflEPRESEMATIVE50FTMISCOUNTYTDENTERUPONTHE , - ; ' . � � ABOVEMENTIONED PROPERTY FOR INSPECT�ON PUAPOSES. . . - . Q COMMENTS � `�' l�d�t` �' _ � ��uT. � � PERMITTEE NM+tE(P'f /�f�.� F , � �1/ L � � V .'I .. '�"'L��.� " II � '. � SKiNp1lIREOFPF.RMITT E i3 DATE ��.� ��.. = RECPT.NO. 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