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Home My WebLink About15294 (19) _..... _. _, _. __._ _ _ .. ____.__ _. .. ,_ ,. , - - __�..- - �.,�„�..,,,>.-.�..�.�.�- : � _ _ _ � �� ,.,�'"-.,a, Y � � �� CITY OF DIAMOND BAR - � DEPARTMENT OF COMMUNITY�DEVE�.OPIvI�NT SERVICES AW • 21660 E.Copley Drive Suite 190 ' (909)860-3195,Fax(909)861-3117 PRE$$ "°"�� BUII.�II��ly"��lMI'1'�.1'PLICAT'ION FIRMLY �,.. .� ,. . ...;:. . ,,. ,: �.. _ . ..,�„ .�. .. , . _,�.. �..:. � JOBSITE � ; r � (�, APPLICATION .-q�,,,�^ PERMIT P/C o ADDRESS ^��'�� " �`�'�'�"� '�""�'°�' DATE !�'ft'J'-C1��' NUMBER � � � # � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GR�UP p OWNER ��•""�d.< �i..��i..- " ADD SS•.��-- ZONING SETBACKS � CITYR��-�'�'';�-�,,;�fa' �`- ZIP�� TEL.' �'"�"I�� REART RW � APPtICANT TEL. SIpEJSIDE STREET RW ❑ zd , .. : � CONTRACTOR ��`"%'��'�� "s"t`�:Cc_��-� SIDE ❑ � ADDR�S `t"� ^3 'r-- ESE:a ."�;� .... .. ........ .. CITY �'�'��-�' ZIP �t 1X-. TEL. ��`"'��,�-' PROPOSED USE '� � Q ARCH/ENG! ' � DESIGNER NO.DWEl.. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCFIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLAFATIpN � SFR/ADD/REM O p I HEHEBY AffIRM UNDER PENALTY OF PEHJURY THAT I AM p(EMPT FROM TNE CON7flACTORS L4 � G2BgBICBfpOII W CENSEUWFORTHEFOLLON7NOREASON(SEC.7o31.5BUSINE55ANDPROFE5510NSCA0E:ANYCITYOR . C� CpUNTYWMqiREWIRESAPERM�TTOCONSTRUCT,ALTER,iMPROVE,DEMOUSH,ORREPA1FiANYSTRUC� W Petio/DeCk Z NRE PRIOFl TO ITS ISSUANCE,ALSO RE4UlRES THE APPUCANT-fOR SUCH PERMIT TO fllE A SICiNEO �� STATEMENT THAT HE OR SHE IS L�CENSED PURSUANi TO THE AROVISIONS OK TH6 CONTRACTOR3 U� � � CENSE UW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF OIVI$ION a OF YNE'BOSINE5S-ANO�PRO. �'�' POOUSpB FE6SIONS CODE)Oq THAT HE OR SHE IS EXEMPTTHER�EFROM AND THE BASIS FOR TN�ALLEGE�EXEMP- TKNi.ANYVWLATIONOFSECT10N7o31.6BVANYAPPLICANTFORAPERMITSUBJEbTSTNEAPPLICAN770 Z Ae-Roof � �CML PENALTY OF NOT MORE THPN FNE HUNDflED DOLLAHS(S5oo).): � � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEE$W17HWAGESASTHEIRSOLECOMPENSATION, C� COlnrtlBfCl81 - NALL DO THE WOHK,AND THE STRUCTURE IS NOT INTENl7ED'OR OFFEFED FOR SALEj$EC.7044,9USI- J NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE UW DOES NOTAPP�V 70 AN OWNER OF y PiIOPERTVWFiOBURDSORIMPROVESTHEREON.ANDWH�ODdES'5lJCHWORKHIMSELFORHERSELFOR = � THROU(iHHISORHEROMMEAIPLOVEES,PROVIOEDTHATSUCH�IMPROVEMENTS'AFl6lJOTINT'�NDEDOF m Q ,OFFEAEDFORSALEIFHOWEVER,7HE8UILDINOORIMpROVEMENt1560LDN11THINONEVEARofCOMM.E- � TION,THE OWNER-BUIIDER WILL HAVE THE BURDEN bFPROVIN�THAT HE OR;SH'E DID NOT BUtID OR IMPROVE FOflT}IE PURPOSE OF SPLE). w ❑I,ASOWNEROFTHEPROPERTV.AMEXCLUSNE�_YCONTRAC71NGlkI7HLICENSEDCONTRACTDRS � TQ CONSTRUC7 THE PR0.1EC7(SEC.7tlM,9USINE55 ANO PROFcSSIONS CODE:THE bONTRACTORS ll- V01U2�iOf1 _ADJ.AREA � CENSEUWDOESNOTAPPLYTO/WOWNEROFAPROPERTYWFIUOUILOSDRIMPRbVESTHEREON,AND NM1iOCONTRACTSFORSUCHPqOJECTSWITHACONlAACTOqCS)�ICBNSEOpURSUpNTTOTHECONTRAG- QUANTI7Y DESCF3IPTION FEE � TORSLICENSELAW.). �� O I MI EXEMPT UNDER SEC. 8.d P.C.FORTHIS REASON Q � � LL � DATE OWNEH v W � LICENSED CONTRACTORS pECLARATION W � 1 HEREBYAFFlRM UNDEFi PENALTV Of PEWURY THAT IAM LICENSEO UNOER PROVISIONS OF CHAP7ER Z �B�-._ ��p»p_�y-��.t�.'�' �/'� n„ B(COMMENCINOWITMSECTION7oo0)OFDIVISION70FTHE'BUSINESSANOPROGESSIbNSCODE,AND t� �"'Fta"+'b�- {J ?S MY IICENSE IS N FULL FOftCE AND EFFECT. e.0 ,f^�' y�_ ''��yd� f� � m O r,;;�h.a-+ LIC.NO. � s'°"l�G.i. . . .. � � UCENSECLASS , , - - � � � ''��y g J U DATE µ�`�°�'% •�-� .+' CONTRACTOR � � """ "�""°"""'.. d �W �� WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNDERPENALTYOFPERJl1RYONEOFTHEf-0LLOWINGOECLARATIONS: fJ5 Q � _IHAVEANOWILLMAINTAINACERTIFICATEOFCONSENTTOSEIF-INSUREWRWOpKERS' _ � COMPENSATION,AS PRQVIDEO BV SECTION 37ao OFTHE LABOR CODE,FpR THE PERFORMANCE � OF TNE WORK f-0R WHICH THIS PEFMIT IS ISSUFA. � O � _1 HAVE AND WILI MAIMAIN WORNERS'CAMPENSATION INSURANCE,AS REQUIRED BV SECTION � 37WOFTHELAHORWDE,FOATHEPERFORMANCEOFTHEWORKFORWHICHTHISP[RMITIS ISSUEO.MY WORKERS' MPENSATIOP!INSURANCE CAR�RIrER PND POLICY NUMBER ARE: CONSTRUCTION jCaRRiER � ��'��"6�-t�-'�*+-�^-�a� �^-�'°"t�'��-'�'�c�� PIAN REVIEW Z PaICYNUMeER ��'� �`C:� ELECTRIC ¢ -� =�� (fFiISSECTqNNE�NOT0E00AR�LEIEDOFhIEPERIMti5FCf7CP1EHUhDHmWILhRS(5 oF F PLUMBING W MECH NICAL �+� � �CEflTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR11'HICH THIS PERF9IT IS ISSUE�.I . C'3 SHALLNOTEMPLOYANYPERSONINANVMANNERSOASTOBECOMESUBJECTTOTHE y WORKERS'COMPENSATION L4WS OF CALIFORNIA.AND ACiREE h1AT IF I SFiOULD BECAME SPECTION FEE SUBJECT TO THE WORKERS'COMPENSATIpN�PROVISfONS OF SECTION 37D0 OF TNE LABOR pp ^ (�}�(9�/,,�� /�--. s CADE,I SHALL FORTHWYfH COMPIV WITV{`7yliOSE PROVISIONS.��""��. �SSUANCE ��'i tl 'i �_�75,t- ' V" �� L Gti L4ly O DATE:��""� APPUCANT. d'--«..�.`�--.�""�...��LL�".� SMIP ^�'� A �qT��}j.� p�y WWARNING:FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNIP.WFUL,AN�SHALLBE ENERGYP/C �" '� '`�a��l�+�s✓3`1!'� � SU&IECTANEMPIOYEfiTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT -�L��..� _ - � DOUARS(51 D0,000),IN AODITION TO TNE COST OF COMPENSArION.DAMAGES AS?pOVIDED FOR IN J SECTION 3�08 OF 7HE LABOR CO�E,INTEFEST,AND ATTORNEY'S FEES. RETENTION FEE: � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � �HEREBYAFFIRMUNDEflPENAITYOFPERJURYTHATTHEREISACONSTRUCTIINJIENpINGAGENCY n- FOft THE PERFORMANCE OFTHE WORK FOR WHICH THIS PEflMIT IS ISSUEp(SEC.30B7,CIV.C.). - Z W � LENOER'S NAME 1= LENDER'SA�ORESS . � I CERTIFf THAT I HAVE READ THIS APPLICATION AND SiATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �� "'�'�p � I AGREE TO COMPLV WITH ALL CITY AND CAUNTY ORDINANCES AND STATE LAWS RELATINa TO BUIL��NO � . � CONSTRUCTION,ANOMEREBVAUTHORIZEREPftESENTATNE50FTH15COUNTYTOENTERUI'ONTHE� - � ABOVEMEfJTIQNED PROPEFi FOR INSPECTION PURPOSES. COMMENTS � � \[".��'"�(�,,,~� � � _...�� Y�' .._�.,-..._.__.,,.,_e ,,, � m PERMITTEE NPME(PRIN� r ___ °°� . Q �..,„„„,_.�:..... � _ '�i��'_...�y+.� �.,� . . . � � SIONATUREOFPERM�TTEE DATE = RECPT.NO. 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