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HomeMy WebLinkAbout15893 (23) fr ��,�� ^�- - -�"' _��,�_ CITY OF DIAMOND BAR �� DEPARTMENT OF COMMUNITY&DEVELdPMENT SERVICES �p�'''3U�o/ w 21660 E.Copley Drive Suite 190 (909)860-3]95 Fax(909)861-3117 ��j� PRESS �'y�" BUII.DING PERMTT APPLICATION ��"� �IRMLY „ . , � JOBSITE �.�^ ,�rc��e�-...�A �� c� l a- � APPLICATION PERMIT P/C o ADORESS •J �. DATE NUMBER p $ ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER C o ADDR�SS_22�3� E.�,E.1/ ` ZONING SETBACKS w CITY ZIP��,�� 3�6-� FRf�NT RW 7 � APPLICANT �/���,SLJtt_�,tl°�5–Z,..C'�,�� REAR � SIDE/SIDE STREET RW O � CONTRACTOR C�i�`� t�r��I�L SIDE � ADDR SS' � CITY ZIP TEL � PROPOSED USE d t� ARCH/ENG/ y�'� C ,z,, DESlGNER �� NO.DWEL. NO. NO. � ADDRESS_ — UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFR/A�D(REM O 1 HEREBY AFFIRM UNDER PENALTV OF PERJURY THA7�AM EXEMPT FROM THE CONTRACTORS LI� G8fdJ0/CBrpOR W C6NSEUWFOHTHEFOLLOWINGREASON�SEC.7031.SBUSINESSANDPROFESSIONSCADE:ANYCITYOR (f) _ V COUNiYWHICHRE0UIRESAPEflMITTOCONSTRUCT,AI,TER,IM7ROVE0EMOLISH,ORREPRIRANYSTALIC� W P8t10/D9Ck NHE.PRIOR TO ITS ISSUANCE,ALSO RE-0UIRES THE APPLICAN7 POR SUCH PERMIT TO FILE A SIGNED �w STATEMENT THAT HE OR SHE IS UCENSE�PURSUAN7 70 THE PROVISIONS OF THE CONTRACTORS�i- W CENSE LAW(CFIAFTER G(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE 6USINESS AND PRO- �'j' POOUS�Jfl FESSIONSCODE)OflTHATHEORSHEISE%EMiTTHEREf-ROMANDTHEBASISFORTHEALLEOEDEXEMP- (� TION.ANYVIOLATIONOFSECTION7031.6BVANYAPP�ICANTFORAPERMIiSUBJECTSTMEAPPLICANTTO Z Re-Raof � A CINI PENALTY OF NOT MORE THAN FIVE NUNDRED DOLLARS(f500).): � ❑I,ASOWNER.OFTHEPROPERIY,ORMYEMPLOYEESIMITIiWAGESASTHFIR50lECOMPENSATION, � Comm0fCi81 - YVILL 00 THE WORK,AND THE STRUC7UFE IS NO71N7EN�ED OR OFFERED FOR SALE(SEC.7044,BUSI- J � NESS AND PROFESSIONS CODE:THE CONTMCTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � PROPERTY WFIO BURDS OR IMVqOVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HEHSELF OR � THf10UGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUC}{�pROVEMENTSARENOTINTEN�E�OR m OOFFEREDGOqSIlEIF.HOWEVER,TNEBULDINGORIMPROVEMENTISSOIDWITHINONEVE4qOFC01.1PLE- Z TWN,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PRObING THAT HE OR SHE DID NOT BUILD OR = IMPROVE FORTHE PURPOSEOF SALE�. W ❑I,ASONMEROFTHEPROPERTY.AMEXCLUSIVELYCONTRACTIN(iWRHLICENSEDCONTRACTOR3 — � TO CONSTRUCTTME PRQlECT(SEC.7C44,BUSINE55 NJD PR3FE^s510N5 CA�[:TNE CONTRACTORS LI� VaI118110f1 _ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERT'WHOBUILASORIMPROVESTHEREON,ANO --�—" � YVFIOCONTPACTSFORSUCHVRPIECTSWIiHAR7NTFACTOR(5)LICE�USEDPUFlSUANTTpTHECONTRAG QUANTITV DESCRIPTION FEE � TORS LICENSE LAW.�. ❑I AM EXEMP7 UNDER SEC. 8.8 P.C_FOR T1i15 REASON Q 03 — — � � — — �c DA7E OWNER_____ U W � LICENSED CONTRACI"ORS DECLAFATION W � I HEHEBY APF6iM UNOER PENALN OF PERIURV THAT I AA1 UCENSED UN�ER?ROVI516N5 OF CHAPTER �r t . Z—L Y(COMMENCINpWITHSECTION7oqojOF�IVI510NJOFTHEBUSWESSANDPROFES510NSCODE.AND Z ____ IfV �C MY IICENSE IS IN FULL FORCE AND EFFECT. t�^ � LICENSE CLASS-. IIC.NO.�`//��{/ / �/� /�/� ,�/ � � `•4 V DRTE CONTRACTON f!F�I��It�.1"'NLd1CSG_ Ll = WORKEiiS'COMPENSATION DECLARATION Q � 1 HEHEBY AiFIAM UNOER PENALTY OF GEPJURV 013E OF THE FOILOWING OECLqRATIONS: Z � _iHAVEANOWILLM`AIWTA�Nf��CERTIFiCATEOFCOF15EiJTT03ELF-INSURE"fORWOFIKE'ii3'�.-� ¢ A 2 COMPENSATION,AS PRO`liDED BY SEC'ION 37a0 GF TME LABOR CO�E,FOR 7HE PERFORMANCE IU OF THE WOHN f-0R WHICH 7FiIS PERMIT IS ISSUED. W � .. . . . . - �. a; � ..,k �HAYE PND 1M19LL MAIMAIN 4VORKERS'COMPENSATION INSURANCE.AS REDUIRED 9V SEC770N 6 57000FTHELA80RCO�E,FORTHEPERFOFMANCEOFTH'cWOflKFORWHICHTI-!ISPERMITIS ISSVED.MVNqRKERS'cL�l+PEIdSAT10NIN3URANCECANRIERANDPOLICYNUMBERRRE: CONSTRUCTION jCAFRIER�+�' _ PLAN REVIEW z POLICY NUMBEP���������__ ELECTRIC Q � (TFiSSELT10N�lEE�NOT9EQJMR.EiEDOFTHEPEPoMSFORONEF7lXJD47EDIXrilARS(S1aDJOGiLESS) PLUMBING C... 'Z I CERTIFY THAT IM THE PERFORMANCE Of TliE WORK FOfl WHICH THIS PEPMIT IS ISSVE�,I MECHANICAL SHALL NOT EMPLOY ANY PEii50N IN ANY MANNER 50 AS TO BECOME Sl1BJECTTO THE � WORKERS'CCMiPENSATIONWWSOFCPLIFOFNIA,ANOAGREETH0.TIFISHDULDBECAME 1NSPECTIONFEE � SU&IECT T0 THE WQRKERS'COMPENSATION PROVISIONS OF E ION 370D Of 7HE IABOR COUE.IS OR'HWITH COMPLY WITH THOSE PR ISSUANCE 4i r � SMIP p DATE: AAPLICANT. � _ � ENERGY P/C WARNIN6:FAILURE TO SECURE WORKERS'COMPENSA7SON COVERAGE IS UNI.AWFl1L,AN�SHALL 8E � SU&IECTANEMPLOYERTOCqIMINALPENALTIESANOCIVILFMESUPTOONEHUNDRED7HOUSAND ENERGYPERMIT DOLLARS(5100.000).IN ADDITION TO THE COSTOF COMPENSATION,�AMAGES AS PROVIDED FOR IN � SECTION370BOFTHFLA80qCODE,INTEREST,ANDATTORNEY'SFF.ES. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: _ � IHEREBYAFFIpMUNDERPENALTYOFPERJURYTHAThiEREiSACONSTRUCTIONLENDINGAGENCY FOR THE PER WRMANCE OF THE WORK FO�WHICH THIS PERMIT IS ISSUED(SEC.3oB1,CIV.C.). Z W — � LEN�EWSNAME__ F— LENDER'SA�DRESS � (/�,y W ICERTIFVTHATIHAVEREADTHISAPPLICATIONAN�STA7ETHATTHEA60VEMFOqMATIONISCARRECT. TOTAL FEES y V� Q I AGREE TO COMPLY W1TH ALL CIN ANO CAUNTV ORDINANCES ANO STATE LAWS RELATING TO BUILDING � CONSTRUCTION.ANDHENEBVAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONEDPROPER7YPOHINSPECTiONPURPOSES. COMMENTS o ,� �' [� � — � PERMI7TEENAAIE(PqINT) � �� �� //7/�'t f� � SIGNATUfl[OFP RMI EE � --T- A�G � RECPT.NO. 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