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HomeMy WebLinkAbout11179 (5) __ _. _ _.. ..�. _..... __.�._. ..r ___ -----��.,�,...._.,_-,_..,�.,�..��._�.._..,....,��.,�m..��;.�,::m..�_ . . _; - C[TY OF DIAMOND BAR C�MMiJNITY D�VET:OP'I�IENT DEPARTI�%1�NT ��� .,,.w 21660 E.Copley Drive Suite 190 T � (909)860.3195 Faac(409)861-3117 � PRESS �"""~ BUILDING PERMIT APPLTCATION FIRMLX ,. ..,. :. Q� JOBSITE +y�(��� 4 1 I �� rj�„�� (}�,-..� tA� DATE CAT�ON s� l-- NU B R� l,�! �/C ADDRES5,r,�[ �,� �"Tl � �� v � APN OT TR T ISSUE TYPE OCC DATE CONST. GROUP p OWNER � k°'7 � ADDRES ZONING SETBACKS gCITY Z p � �'(' �. j � REAR� RW ❑ APPLICANT TEL � � SIDFJSIDE STREET RW ❑ � CONTRACTQ� , �� SIDE ❑ ADD ESS ��' � CITY �g -E' I *ZIP '° TEL. 1 PROPOSED USE � QARCH/ENG/ "'���.����� � w OESIGNER NO.DWEL. � N0. NO. a ADDRESS � CI'fY Z{P TEL. UNITS STORIES BEDROOMS � N DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFR/ADDJREM O p I HEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM-THE CONTRACTOq$LL GflfHg9/C3fPOR W CENSEUWFORh1EFOLLOWINGHEASON(SEC.7a31.58U51NES5ANDPROFESSIONSCADE:ANYCIT/OR (n U COUNTYWFtICHRE0UIRESAPERMI7TOCANSTRUCT,ALTER;IIAPqOVE,DEMOLISH,ORHEPAIpANVSTRUC- �jJ pg[iW�9Ck � TUHE,PRIOR To ITS 6SUANCE,AL50 REOUiRES THE APV�ICANT FOR SUCH PERMIT TO FILE i151GNED W STATE4IENT THA7 HE Oit SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CDNTRACTpHS LI• W � CENSE LAW(CHAPTER 9(COMMENqNtl W�TH SECTION 7000�OF D�VISION 9 OF THE BUSINE33 AND PRO- �'L' POOUSpB F FESSIONSCOOE�ORTHATHEORSHEISEXEMP7THEHEFROMANO7HE9�SSISFORTHEALLEOEDEXE6IP- (�J U 710N.ANYVIOUTIONOFSECTION7037.58VANYAPPLICANTFORAPERMITSU8JEC757HEAPPU6ANTT0 Z Re-Roof � ACIVIL PENALTV OP NOT MDRE THAN FIVE HUNDRED�DOLLARS(f500}�J: -� � � � OI,ASOWNEROF7HEPtiOPERtt,ORMYEMPLOVEESWITHWAOESASTHEIRSO4ECOMPENSA710N, � Comm0fCi81 WILL 00 THE WORK,ANO THE STRUGTURE IS NOT IN7ENDED DR OFFEREO FOR SAIE(SEC.�OA4.9U51• J N NESS ANO PROFESSIONS OOOE:TNE CANTRACTORS LICENSE�hW DOES NOT APP{.V 70 AN OWNER f3F = . PROPER7Y NM08UIL05 OH IMPROVES THEREON,AN�WHO DqES SUGH WORK HIMSELF OR HERSELf OR pC THRWGHHISORHEROWNEMPLOYEES,P0.0VIDEDTHATSUCHIM7ROVEMENTSAFENOTINTENDEDOR � � OFFEREDFORSPLE.IF,HOWEVER7MEBUILDINGOFi�MPROVEMENTISSOlDW9THIN<fNEYEAROFLOl.1PLE- � TION,THE OWNER•BUILUER WILL HAVE THE BURDEN OF VROVING THAT HE OR SHE DID NO7 HU11A OR = IMPROVE FOR THE PURP0.SE OF SALE). w ❑I.ASOWNEROFTHEPROPERTY,AMEXCWSIVELVCONTRACTINGNAiFILICENSE�CONTRACTORS � TO CONSTRUC7 THE PR0.1EC7(SEC.7oa4,BUSIHE55 AND PROFESSIONS CqOE:TFIE CANYiiACTOR3ll- VHIU8ti0� ADJ.AREA W CENSEUIWDOESNOTAPPLYTOANOWNEROFAPROCERTYWH08l11LOSORIMPROVES�T1iEREON,AN� � wHOCONTRACTSFORSUCHPRWECTSWIhIAO�N7RACTOR(&)LICENSEDPUR6UANTTOTHEC�NTRAO QuaNnrv OESCRIPTION FEE � TORS LICENSE LAWd. O Ll I AM E%EMPT UNDEA SEC. B.3 P.C.fOR TNIS REASON Q � U LL � OFTE OWNER U Z W � LICENSED CONTRACTOFiS DECLARATION W � 1 MEREBV AFFIRM UNOER PENALTY OF PERJURV THA71 MI LICENSED UNDER PROVISIdJS OF CHAPTER � d a(COMMENCING WITH SECT�ON 7oa0�Of DIYISroN 3 OF THE BUSINESS M1D PROFESSiONS CODE,AND Z X MV IICENSE IS IN FULI FORCEAN�EFFECL m LlJ .'� �+'•. . � LICENSE CLASS���� � LIC,NO. �" � �` � � OATE (" - CONTRACTO r. `�E 6J. W � WORKERS'COMPENSA710N DECLARATION ,�2���� U � C/ � � I HEqEBY AFFIRM UNOER PENALTY OF PER.IURY ONE OFTHE fOLLOWING DECURATIONS: z O _I HAYE AND WILL MAINTAIN A CERTIFICATE OF CANSENTTD SELF•INSURE FOR WORKERS' _ Q CAMPENSATION,AS PROVIDEO BY 3EC710N 370o OF 7HE LABOR CODE.FOR 7HE PERFORMANCE �U OF THE WORK fOR WHICH THIS PERMIT IS ISSUEO. � I LI t HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION Q370o OF THE LABOR COOE,FOR 7HE PERFORMANCE oF THE WORK FOR WHICH TFIIS PERMIT IS J ISSUEO.MV WOpr���RS'COMP ATION INSURANCE CARRIER AND'POLICV NUMBERARE: CONSTRUCI7ON j CAFRIER `�--��1 .��� PLAN REVIEW Z POLICYNUMBEH �" � �� �'` ��� ELE �_ 4 � (fHISSECTIONNE�NOTBENH�LE�EDOFTHEPEPIXTISFtlRONENUM)REOOOLLARS(E100)ORLESS} PLUMBING i � �... w �" Z I CERTIFV THAT IN THE PERFORMANCE Of THE WORK FOR WHICN THIS PER6fIT IS ISSUED,I CHANIC� (3 SMALL NOT EMPLOY ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE � WOHKERS'COMPENSATIONL4WSOFCAUFORN�A,ANDAGREETHATIFISHOULD9ECOAIE INSPECTIONFEE = SU&IECTTOTHEWORKERS'COMPENSATIONPRO�NSIONSOF$ECTWN37000FTMELAB R p� aq $� Q CODE,I+SqHAfI..L,FOHTHWITH COMVLV WITH TiC�PRO � ��� ISSUANCE aI IL�Y d R � *4 t p DATE: ' 0�_�e � APPUCANT:; ��/ SMIP � J WARNIN6:FAR.URE?OSEWREWOHKERS'COMPE SA7IONCqvERAOEISUNLAWFUL,ANDSHALLBE ENERGYP/C � SUBJEC7 AN EMPLOVER TO CRIMINAL OENAL7IESAND CIVIL FlNES I1P TOONE HUN�REO7HOUSAND ENERGY PERMIT DOLLARS(SiaO,000),IN AODtT10N TO THE COSTOF COMPENSATION,DhMAGE6AS PpOVIDEO FOR�N aSEC710N 3lae OF 7HE LA60R COOE,iNTEREST,AND ATTORNEY'S FEES. RETENTION FEE: pW,. CONSTRUCTION IENDING AGENCY PRE-ALT FEE: O � I HEFEBV AFFIRM UNOER PENALTV OF PEFilUqY TFNT THERE IS A CONSTRUCTION IENDING AGENCV FOR TME PERFORMANCE OF TNE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CN.C.). Z W � LENOER'S NAME F— LENDER'SAOORESS .:.......... .. .� .,- .,..,. . ......,;...,.. � TOTAL FEES ���j . '� W ICERTIFY7HATIHAVEREADTHISAPPUCATIONANDSTATETHATiHEABOVEINFORMATIONISCARRECT. � I AGREE TO CAMPLY WITH AlL CITY AND COUNTY OHDINANCESAND STATE IAWS REUTINCi TO BUIIAINCi . � CANSTRUCTION,ANOHEHEBYAUTHORREREPRESEMATIVESOFTNISCOUNTYTOEN7ERLIPONTHE . Z ABOVE�MENTIONED PROPERTY FOR�NSPECTION PURPOSES. . - o GOMMENTS :f- —' �� ,�-�:v'i � � m PERMITTEE (PRI �'p ('� I �l_ ��i��� I"� . [�/] " �� I+"��(� i �i` � , � s ran'ruq PERMITfEE � - DFTE RECPT�� PAID BV VALIDAT70�� � � � . .. .. ... .. 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