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HomeMy WebLinkAbout16185 . ._,_ •�,,_...._,_\ CITY OF DIAMOND BAR 1' �---�— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE � � P y 90 PRESS . ;V, (909)860-3195 Dnve Smte 13117 � . . Farz(909)861- a 21660 E o e ;�'�' BUII.DING PERMIT APPLICATION , ., , ; ..{, , , .,, ,... FIRMLY . } JOBSITE ���� �. �y �j�� y� /� DATE CATI�-��� . NUMBER m #/C�./ �� { a ADDRESS � �••��-�"�- -n.pE ,,, OCC � APN LOT TRACT D TEE ��������L CONST. GROUP p OWNER '���' o ADDRESS �e4w`� [ ZONING SETSACKS Z CITY ZIP TEL.�_I��^� FRONT RW ❑ g APPIICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR � SfDE ❑ � ADDRESS A ` ' PROPOSED USE 40 ' �'✓r'�'V� CITY r n.j ZIP���TEL. ��- "' w ARCWENG/ �.��,� z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZiP TEI.. _ � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/RDO/REM O �] 1 HEREBY AFFIPoN UNDER PENALTY OF PERJURV THAT I AM EKEMPT FROM THE CONTPACTORS LI- G8f8J0/COfPOfI W CENSEIAWFOHTHEFOLIOWINGREA50N(SEQ7o31.58U31NES9ANDPROFES510NSCODE:ANVCINOR (� C� COl1NTYWHICHREOUIRESA7ERMITTODONSTRUCT,µTER,IMPROVE,OEMOLISH,ORREPAIRANYSTRUC- W pdtl0/DBCk �� 1i1FiE.PRIOR TO ITS IS9VANCE,ACSO REQUIRES 7HE APPLICANT-FOR SUCH PERFIIT TO F0.E A SIGNED � STA7EAIENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- � CENSE lAW(CHAPTER 9(CqNMENqN6 WITH SECTION 7000)OF pIVISION 3 OFTHE BUSINESS AND PRO• u' POOVSpB fESSIONSCODEJOR7HATHEORSHEiSEXEMP77NEREFROMAND7HEBASISFORTHEALLEOE�EXEMP- — TION.ANYVIOUTIONOFSECTION7031.SBYANYAPPLICANTFORAPERMRSUBJECTSTHEAPPLICANT70 Z q�-Roof � ACML PENALTY OF NOT MORE THAN KNE HIJNDRE�DOLURS(5560).j: � � 04���"�NEROFTHEPHOPERTY,ORMVEMPLOYEESWITHWAGESAS7FIEIR90LECAMPENSA7ION, CI Commercial - WILL DO THE WORK,AND THE STRUCTUHE IS NOT INTENDEO oP pFFEFED FOR SALE(SEC.7o44,BU51� ,J NESS ANO PROFESSIONS WDE:THE CONTRACTORS IICENSE LAW OOES NOT APPLY TO AN OWNEP OF � PROPER7YYJI�IOBUIl0.SORIAIPROVESTHEREON.ANDWHODOESSUpiWORKHIMSELFORNERSELFOR � � THRdJpHHISORHEROWNBAPLOVEES.PROVIDEDTHATSUCHIMPROVEAIENTSdRENOT�NTEN�EDOF � Q ,OFFEREDFORS/�LEIF,HOWEVEfi,TNEBUILDINGORIMPROVEMENTIS50LDWITHINONFVEAROFCOMPIE- Z TION,THE OWNEH-BUILDER NlILL HAVE THE BURDEN OF PROV�NG THAT HE OA SHE DIb NOT BUIID Oq = IMPROVE FOR THE PURPOSE oF S,q�E). � � �� � � ❑I,AS OWNER OF7HE PflOPEflTY,AM EXCLUSIVEI.Y CONiR4C71NG N17N UCENSED OJNTRACTORS � TO CONSTRUCT THE PROJECT(SEC.1044,BUSINESS AND PROFESSIONS CODE:THE CONTflACTORS LI- ValU8t10n ADJ.AREA W CENSEUW�OESNOTAPPLVTQAN04VNEHOFAPROPERNWfibBUILOSORIAiPRCVES7HcqE�N,AND � WFIOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)iiCEN5E0PUR5UANTTOTHECONTRAG QUANTl1Y �ESCRIPTION FEE � TORS UCENSE UWJ. - — p� �j� - Q ❑I AM IXEMPT UNDER SEC. , ._—B.8 P.C.FOR THIS REASON U 4"�'`I 'Ca.- � � � --- - � �_ ' �c� � DATE _ OWNER_ 'W .1 t. � UCENSED CONTRACTORS DECLARATIOP� � � I HEREBYAFFIflM UNDER PENAI.TY OF PERJURV THAT i AN LICENSED UNDER PRONSIONS OF CNAPTER � � Y(COMMENCINQ WITH SECTKKJ i000)OF CIVISION 3 OF THE BUSINESS AND PPOFESSIONS CODE,AND Z MY UCENSE IS M NlL FO E ANO EFFECL � y�t � o LICENSE CLASS LIC.NO. K.yL�,�_��I.��/ J V ORTE_�7��_�� CONTfiACTOR.�_�;eq,r�,�c� tl � c9 e v��Y�� � WOftKERS'COMPENSRTION DECL.HRATION �' �� � � � 1 HEREBV AFFIRM UN�ER PEFIALTV GF 7ERJURY OP1E OFTHE FOLLOWING OECLAFATlONS� z � �J 4 � _IHAVEANOWILLMIIINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORNERS' _ �� COMPENSAYION,ASPflOViDEOBYS[CTION37000FTHEI.A60RC6DE,FORl'HEPEHFORMANCE W OFTIIF WORK FOR 4°f4i�CH THIS AFRMR IS ISSUEO. � p W _IHAVEMlDWILLMAIMfAINWORKERS'COMPEWSATIONINSURANCE,ASREOUIflEDBYSECTION � Q 37000FTMELABOr�COOE,FORTNEPERFOqMANCEOFTHEWORKFORN'HtCHTNISP�RM1Ti5 � o ISSUED.MY WORKERS'COlAPENSATION IMSUHANCE CARRIEiiAND POLICY NUMBERAFE: CONSTflUCT�ON j �qqpiEq _ _ PLAN REVIEW z PouCVNU�aBER_ ___._— ELECTRIC ,Q _ � (fHtS$ECfqNNEIDhpT6EUJMFt.EfEDOFh�EPEFApLISFORONEI�R1NIXiE60q1AR5�51W)ORLFSS). PLUMBING ,'�� ICER77FY TNAT iN THE PERf-0RMPNCE OFTHE W�PK FOq WHIL'HTHIS PERMIT iS ISSUED,i MECHANICAL �,J' SHALLNOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE � WORKERS'COIdPENSATIONLAWSOFCAIIFORNIA,ANDA.GR[ETHATIFISHOULOBECOME INSPECTtONFEE SU9JECT TO Tr1E WORKERS'GOMPENSATION?ROVISIONS OF SECTIfNi 370o OF THE LAOOP � CO�E.t SHALL FOYITHWITH COMPLY WiTH THOSE PROVISIONS. ISSUANCE 0 SMIP p DATE: APPLICAN7: . _— . � � �NERGY P!C WARNING:FAILURE?O SECURE WORKERS'COMPENSATION COVERqGE IS UNLAWFUL,ANp SHALL BE � SUBJECTANEMFLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUN�REDTHOUSANp ENEFZGYPERMIT OOLLnRS(S'�.�).IN MDITION TO THE COST OP COMPENSATION.DAlAAGES AS PROVIDED fOR IN � SECTiON 37080F THE LABOR CO�E,1NTEREST,AND ATTORNEV'S FEES — AETENTION FEE: � CON3TRUCTION LENDMG AGENCY PRE-ALT FEE: � I HERE9Y AFFIRM UNDER PENALTY OF PERIURY THATTHERE�5 ACONSTRUCTION LENDING AGENCV FORTHEPERWRIA:INCEOFTHEWORKFOFWNICHTHISPERMITISISSUE�(SEC.30H7,CIV.C.). �� � �� W — � LENDER'SNAME __—_ - F— LENDER'SADDRE55_ _ — — � � � ICERTIFYTHATIHAVEREA�1'HISAPPI_ICATIONANOSTATETHATTHEA80YEINFORMATIONISCORRECT. TOTAL FEES � � �. W I AGREE TO COMPLY W1TH PLL CITY AN�COUNTV ORDINANCESAND STATE LAWS RELRTING TO BUILDING � CONSTftUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OK THIS COUNTY TO ENTER UPON THE � F80YE-ME EO PAOPEftTYFOR INSPECTION PURPOSES. 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