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HomeMy WebLinkAbout10454 , �x �_/`` � � W CTfY OF DIAMOND BAR COMMUNITY I)EVELOPMENT DEPA TMENT EXP j��� :,� 21660 E.Copley Drive Suite 190 PRES.S (909)860-3195 Faz(90§)$61-311'7 """'s BUILDING PERMIT APPLICATION �C T Q �j �� FI R M LY 22824 HILZ�T FiFAD #761 ;,: ,w` ' �C>'�'..�� .,,:. . �,, � JOBSI7E APPLICATION PERMIT �' P/C o ADDRESS DATE ' NUMBER # c� ISSUE d,/� y� ,-�, TYPE OCC APN LOT TRACT DATE "�`s t � ;�� CONST. GROUP p OWNER �_�nd &�Y �j�Sll71S CIUb �+- C O r ive PO �X 400 ZONING SETBACKS ADDRESS _ �rtY �• z CITY �� ZIP �z� TEL — � FRONT �{/y p g APPUCANT Iarrv Sta.c�3Pn TEL.�.���4 REAFi p � $IDEISIDE STREET RW ❑ � CONTFACT � �-9h� � �c• SIDE ❑ ADDRESS ���i�a ����e o �i-Ty Zip 9 710 TE�, 909) 597-773 PROPOSED USE w ARCWENCa/ �zDESIGNER �a a ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNI7S STORIES BEDROOMS � u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION p� OWNEp•BI:ILDER DECLARATION SFR/ADD/REM O I HEREeY AFFINM 11NDER PENALN OF PERJURY THAT I AM EJfEM7T fROM THE CONTRACTORS LI- Gef8CJ0lC8lp0A W CENSELAWFORTHEfOLLOWINGREASON�BEC.)0.91.5BUSINESSANDPROFE§SKYNSCO�E:ANVCITYOR (n U COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCLAL7ER,IMPRDYE,DEMOUSH,ORREPAIRANYSTRUG W PatiOJDBCk TURE,PRIOR TO ITS ISSUANCE,l�LSO REW IRES THE APPLICANT FOR SUCH PERIAIT TO FILE A SIGNED � STA7EMENT THAT HE OR SHE IS UCENSEO PURSUANT TO YHE PR0V1310NS OF THE CONTRACTOR$LI- � CEN&E UW�CHAPTER 9�COMMENGNO WITN SECTION 7000)'OF OIVISION�3 0F THE BUSINES$AN�PRO- POOVSpe � FESSIONSCODE)ORTHATHEORSHEISEXEMPT7HEHEFROMANDTHEBASISFORTHEALLECiEDEXEMP- (� V 710N.ANVVIOlA710NOF5EC'tION7077.5BVANVAPPLICANT'fORA�PERMITSUBJE'CTSTHEAPPUCANiTO Z RB-ROOf A CML PENALN OF NOT MORE THAN FNE HI/NDRED DOLLApS(S50oj.): Z ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWApESASTHEIRSOLECOMPENSATION, � COf17m6�Cle� WILL DO 7HE WORK,AND 7HE STRUC7URE IS NOT MTENDED OR OFFENED FOR SALE(SEC.7044,BU51• _.J � NESS AND PR06ESSIONS COOE:THE CQNTFlACTOpS IICENSE LAW OOES NOT APPLV TO AN OWNER OF � PROPEH7Y WHO BUIl�50R IMPROVESTHEREON,ANp WHO dOES$UbH WORK HIM9Elf OR HEhS�LF bR CL THROUGHHISORHERONMEMPLOVEFS,PROVIDE�THAiSUbHIMPROVEAfENTSARENOTINTENDEDOR m QOFFEREOFORSALEIF,HOWEVERIHEBUILDINGORIMPROVEMENTIS501AWITHINOf1EYEAROFCOMPIE- z 110N,iHE OWNER-BUILDEFl NALL HAVE 7HE BURDEN OFPROVING TNAT ME OR�$HEDID NOT BUIIA OR � IMPROVEF�ITNEPURPOSEOFSALE). O I.AS ONRJER OF THE PHOPEH7Y,AM E%ClU51VELY CONTRACTINO WITH LICENSW CONiRAbTORS TO CONSTRUCT THE PRQIEC7(SEC.70bt.BUSINESS AN�PROFE$SIONS CADE:THE CONTRACTORS U� V81118fiOn ADJ.AREA � CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPER7V'WHPBUILDSOR�IMPROVES7HEREON;AND � WHOCONTqqC7SFORSUCHPROJECTSWiTHACANTRACTOR(SIUCENSEDPURSUAN"fTOTHECONiRAG QUANTI7Y DESCRIPTION FEE � TORSLICENSELAW.). � ❑I AM EXEMPT UNDER SEG ___ __9.S P.0.FOR THIS REASON Q � Fil � U � � �ATE OWNER U O W � LICENSED CONTRACTORS DECLARATION W � I HEflEBYAFFIFM UNOER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAP7ER � � 9(COMMENCING`M7H SECTION 70ao)OF DIVISION a OFTHE BU51NE5S AND PROFES510NS CODE,AND Z 'X MY LICENSE IS IN FULL FORCEAND EFFECT. m 0 UCENSE CLASS C10 ��c.No. 729594 � V DATE CONTRACTOR�� -� �� � � O-. W � WORKERS'COMPENSATION DECLARATION ���� � � -� ���� ���� ¢ � 1 HEREBYAFFIRM UNDER PENALTY OF PEFiJURY ONE OF THE FOLLOWING DECLARATIONS: � � _IHAYEAFAWILLMAIN7NNACERiIFlCATEOFCONSENTTOSELf-INSUREFORWORK[RS' _ � COMPENSATION,AS PROVI�ED BV SECTION 3700 OFTHE IA60R CODE,FORTHE PERFORMANCE 'U OFTHE WOFiK FOR WHICH THIS PERMIT 191S9UED. ,� � � _I HAVEAND WILL MAINTAIN WORNERS'COMPENSATION INSURANCE,AS REQU�RED 8Y SECTION QQ 37aoOP7HE 1.A80R GO�E,FOR THE PERFORMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED.MV WORKERS'COMPEN9ATION INSUHANCE CARRtER AND POI.ICY NUMBERARE: � COPISTRUCT�ON j CARRIER ���t �-�.�.�-y^�--�+S8t10TI _�?4,�,IN REVIEW � POLICVNUMBER TWN96627901-02 .._ LECTRi�' � ';? . _ r' �- .¢ � (rt+ssE�noMNe�No7eEooMR.eTeooF'n1EaEw,MrlSrilRon�EFaM%iEoOauwSR��)«+LEssl� PLUM8ING Z 1 CEflTIFYTNAT INTHE PEflKORMANCE OFTHE WORK fOR WHICHTMIS PERMIi IS ISSUED,I MECHANICAL (� SHAII N07'EMPLOY ANV PERSON IN pNY MANNER SOAS TO BECOME SUBJECTTO THE � WOPoCERS'COMPENSATIONUWSOKCA�IFORNIA,AND"'REE7HA7"�F'IS-'ULD'BECOME� ' INSPECTIONFEE � SU&lEC TO THE WO�KEAS'CAMPENSATION PROVI S OF CTbN 3 OF THE IABOR J�✓✓"` -"'" � OE, HAlLFO WITHCOMPLYWITHT VISION ��ISSUO ANC�:� 1 o SMIP p �ATE: �APPUCAM: ;,- ..�` �W ENERGY P!C WARNINQ;FAILURETOSECUREWORKERS'COMPENSATIONCO RAGEISUN.AWFUL,ANDSHALLBE � � � LL SUBJECTANEMPIOVERTOCRIMINALPENALTIESIW�qVIIFINESUPTOONEHUNDREDTHOUS/W0 ENERGYPERMIT DOLLARS(S7 00,000).N PDDITION TO THE COST OF COMPENSATION,�NAAGES AS PROVIDED FOR IN � SECTION 3708 OF THE LABOR COOE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: f d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ���,g'�R J �! �Ck('�`�- - e t 0. I HEREBV AFFIRM UNDEfl PENALTY OF PENUqV THAT 1"HEFE IS A CONSTRUCTION LENOING AGENCY ������� � FOR THE PERf-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS�SSUED(SEC.3097,CIV.C.�. W � IENDERSNAME F-- LENDERSPDDRESS . .. .:': ...,:.:.. -: �.�:.-:_:::.,�;�.�I...,. w ICEFiTIFYTHATIHAVEREADTH�SAPPLICATIONAND5TA7ETHATTHEABOVEINFORMATIONISCARRECL TOTAL FEES � E{J��' ,�,_,. �' �� � I AOREETD COMPLV WITHAIL CIN AND COUNTY ORDWANCES ANO STATE lAWS REL4TMG TO BUIIDING . . � CONSTRUCTION,ANDHEREBYAUThIOR2EAEPRESENiATIVE50FTHISCOUNTYTOENTERUPONTHE ' ' ' ' ' z ABOVE-MENTIONEU PHOPERiV FOR INSPECiION PIIRPOSE5. COMMENTS � � � . .... ... 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