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HomeMy WebLinkAbout10184 C1TY OF DIAMOND BAR � COMMUNITY DEVELOPMEN'f DEPARTMENf� .;,.W 21660 E.Copley Drive Suite 19d PRESS (909)860-3195 Fax(909)861-3117 �"'"'" BiJILDING PERMIT APPLICATION FIRMLY o� JOBSITE ` )� APPUCATION PERMIT G� P/C " ADDRES faJ C' ' DATE ��� �� NUMBER���� d # � ISSUE � TYPE OCC APN LOT DATE ����� CONST. GROUP p OWNER - � ADDR S ZONING SETBACKS g� FRONT RW ❑ CiTY TEL. O APPLICANT ��, REAR p � SIDE/SIDE STREET RW ❑ � CQNTRAC O ( SIDE ❑ o ADDRES PROPOSED USE W��� f �D GI CITY ZIP . D� w ARCH/ENG! y^� ,�,,� y W DESIGNER�/'7��LJ►`V' , NO.DWEL. a ADDRESS ' • � � CITY ZIP TEL. UNITS ORIES BEDROCfMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BL'ILDER DECLARATION SFR/ADDlFiEM O I HEfiEBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTMCTOFYS 41- G8189H/Ce1p011 W CENSELAWFOHTNEFOLLOWINGREASON(SECJ0.77.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR (n C.> CAUNTYWHICHREDUIpESAPERMITTOCONSTRUCT,AITER,IMPROVE.DEMOLISH.ORREPAIRliNYSTRUC- W PatiO/peCk Z TURE,PRIOR TO ITS ISSUANCE,.4L50 RE�UIRES THE APPLICANT FOR SUCH PERMI7 TO F�LE A SIGN�D w STATEMENT THA7 HE OR SHE IS UCENSED PURSUPNT TO THE PROVISIONS OF THE CONTRACTORS U- w � CENSE LAW�CHAPTER D(COMMENCINfi WRN SECTION�000)OF DINSION 3 OF THE BUSWESS AND PRO� LL' POOUSPB FESSIONSCADE)ORTHATHEORSHEISEXEMPT7HEREFROMANpTHEBASISFORIHEALlEO'EtlEXEMP- (� � TIDN.ANYVIOLATONOFSECTION7031,SBYANVAPPLICANTFOHAPEHMITSU&IECTSTFEAPPLICKNTTO z Re-Roof �� � ACIVILPEN0.LTYOFNOTMOFlE7HANFIVEHUNDREOOOLLARS(5500).�: '� ' Z ❑I,ASOWNEROFiHEPROPEfi7Y,ORMYEMPLOYEE5WI7HWAGESASTHEIR50LECOMPENSATION, � COrtIrtlOrCial . WII.L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7047,BU$1� J � NE55 AND PROFESSIONS CADE:THE CONTRACiOPS LICENSE LAW ODES NOT APPLV TO-/iN OWNEP 6F PROPER7VWe�lOBUILDSORIMPROVESTHEREON.ANDWHO'�OESSUCHVdORKHIAdSELFORHER�SEIFdR � � THROUGHHISORHEROWNEMPLOVEES.PROVIDEDTNATSUCHIMPROVEMENTSARENOYINTENOEDdR m � OFFEHEUFORSALEIF,HOWEVERTMEBUIIDINGORIMPROVE'MENYISSOLOWITHINDNEVEAPOFC061P1E� Z TKKJ,THE OWNER-BUILDER WIU.HAVE THE BUPOEN OF PftOViNff THAT HE OR SHE'b10 NOT BUILD dFl IMPROVE FOR THE PURPOSE OF SALEJ. ' W OI,ASOWNEROFTHEPROPERTY.AMEXCLUSNELYfANTRACTMGWITNLICENSEDCqNTRACTOqS � TO CANSTRUCT THE PROJECT(SECJ044.BUSINESS AN�PROFESSIONS CODE:THE 60N'i'RACTORS U� VelUetlOn _.�0� ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROfAPflOPERNWHOBUILDSORIMPROVESTHENEON,ANO = WHOCONTRACTSFORSUdiPqOJECTSWITHACONTRACTOR(S)LICENSEOPURSUANTTOTHECQNTR4C- FEE � T00.SLICENSELAWJ. � QUANTITY DESGRIPTIqN � O I PM E%EMPT UN�ER SEC. B.&P.C.FOR THIS PEASON Q ?.� U � � DATE OWNER F- . � W � UCENSED CONTRA¢TORS DECLARATION W � i HEREBV AFFIRM UNDER PENALTY OF PEAJURY TFi�T IAM L�CENSED UNDER PROVISIONS OF CHAPTEq' � a, B(CAMMENCING WITH SECTIO 7000)OF DIVISqN 3 0F 7HE BU51NE55 AND PROiES5iON5 CADE,AW' Z X MY LICENSE IS IN FU CE ND EFFECT, W �/;,.� - � m � LIGENSE GLASS � � IIC.NO. _ � V DA7E CONTRACTOR� � a W � WORKEHS'COMPENSATION DECLARATION � � I HEREBYAFFIRM UNDER PENALTY OF PERIURV ONE OFTHE FOLLOWING DECLARATIONS: z � _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT 70 SELF•INSURE FOR WORKEflS' � Q2 COMPENSA710N,AS PROVIDED 8Y SECTION 37000F THE LA80R CAOE,FOR THE PERWRMANCE U O OF THE WOHH FOR WHICN THIS PERMIT IS ISSUED. � �w _I MAVE AN011�L1 MAINTAIN WORKER5 CAMPENSATION INSURANCE,AS RE0UIRED BY 5EG710N 3700 OF THE LABOR CODE,FOR THE PERWRMANCE OF THE WORN FDR WHICH THIS PERAUTIS �O�A �/�� ISSUED.MYWOpKERS' NPENSA710N�ANCEC RRIE$�1NDPOUCYNUMBERARE: CONSTRUCTI . �" � —� A / / 7 � CARRIER �V j��� PLAN REVIEW ZroucvNUMeEa . ELECTRIC Q � (1HISSECTiONNE�NOTBEO�MPLETmOFTHEPE(iMIfISFORONEIiUt�pRmOqlf�RS(5100)ORLESS}. PLUMBING Z I CER7IFY THAT iN THE PERFOFiMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�.I MECHANICAL � C�S SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBEGOMESUBJECT70THE � WORKERS'COMPENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOULpBECOME INSPECTIONFEE � SUBJEC7 T THE flKER5'COMPENSATION PROVISIONS OF S� N 370�Of THE LABOR �@0 �Q � CODE,i S WITH CAMPLY WITH THOSE PROVI IONS. SUANCE d O @ p DATE: APPLICANT: MIP • d O � WAHNINO:FAILUR T SECURE WORKERS'COMPENSATION COVERAOE IS UNUWFUL,AND SHALL BE ENERGY P/C �y, SU&IECTAN EMPLOYERTO CRIMINAL PENALiIES AN�CIVIL FINES UPTO ONE NUNDFEO THOIlSANO �NERGY PERMIT OOLLAfiS(S1o0.oa0),IN AO�ITION TO THE COST OG COMPENSATION,OAFAAOES AS PRONOEp FOR IN � SECTION87o80F7HELABORCODE,INTEREST,ANDATTOqNEY'SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEfiEBY AFFIRM UNDER PENALTV OF PERJURY THATTHERE IS ACONSTqUCTION IENDING AGENCV FOq THE PERFORMPNCE OF THE WOi7K WR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV.CJ. Z W � LENpER'S NAME i-- LENDER'S AD�RE55 W ICERTIFYTHATIHAVEREADTNISAPPLICATIONANDSTATETHATTHEABOVEWFOR4tATION15CORRECT. TOTAL FEES ��1 �D� � IAOREETOCOMPIVWITHALLCITYANDCOUNTYORqNANCESANDSTATELAWSRELATINGTOBUIIDING � � CONSTRUC710N,ANDHEREBYA RIZEFEPRESENTATWESOfTHISCWNTVTOENTEflUPONTHE - � � � A90VE•MENTKKJED PROPEPTY R I ECTION PURPOSES. COMMENTS - o � � �, .._ . ` J � � m PERMITTEE NAME(PRI �� � � � � � SKiNATURE OF P 1T DA �p � � , � RECPT.NO. �� �� PAID BY B� � . � .VALIDA�'ION u WHITE— anment Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENROD--File Copy,GREEN—AppUcanPs Copy . _ . � , . , . . _ .;.- _ . t ., r ,. r, . -:-. 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