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HomeMy WebLinkAbout11764 (5) CITY OF DIAMOND BAR �` r , . `` �' .'-. .._ : � k �--J�� Y&DEVELOPMENT SERVICES DEPARTMENT OF C�MMUNIT 21660 E.Copley Dnve Smte 190' �" " y ' PRE$$ `w (809)860.3195 Fax(909)861 3117 M�°�- B�,DII��p`��irr AP�"t.i��'t'i��' ` I � ��� FIRM�Y .:. , t ,.0 ..�: ..,, . .;. .�Y� �. . . ,.,. . . , ,. . , . ,.,.. .` ..,::: rn .;:ii-4,�wAh:.'„3;6,�b'vxr s �hI'�.u.,: ^.i� �� -`'_' 7". ;� -L'�I�!' _., � .. .. � :Z �� APPLIG�ATI��I � . , PERMI7'` . P/C ' � JOBSITE � o ADDRESS r DATE -- .. . � NUMBER ri c� , ISSUE_ TYPE _ OCC �-- APN LOT T ACT DATE' "" ` " "' 'CONST. GROUP p OWNER r , ;. � ,,___ p AD SS c�1 " ZONING SETBACKS W ,, ,, FRONT RW p � CITY � ZIP TEL � '" REAR ❑ APPLICANT TEL. - SIDE/SIQE STRE�T RW ❑ � CONTRACTOR � "1 C (� --e'� SIDE ❑ o� � �,::, I ` Q ADDR S PROPOSE�USE �-C ' o CITY ��_ ZIP �7` TEL. w� ARCH/ENG/ � DESIGNER NO.DVJEL. NO, NO. ADDRE$S UNITS STORIES BEDROOMS � CIT! ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cn �y OWNER-BUILDER OECiLARATION SFR/ADD1i3EM O p 1 HEREBY AFFlRpI UN�ER PENNLTV OF PER.NRY THAT I AM EXEMPT fROM THE C6NTRAC70R5 ll� � GaragelCaiport ud CENSEUWGOR7F�FOLLOW�NGREASON(SECJo31.6BUSNESSANDPROFESSIONSQ00E:ANYC�NOA G� COUNTYNRIICHNEWIRESAPERMITTOCONSTRUC7.ALTEFl.IMPROVE,OEMOLISH,ORREPA�RANYSTRUP w pyt10/DBCk Z TURE,DRIOR TO ITS�SSt1ANCE,AL50 RC-0UINES THE APPLICANT FOR SUCH PEHMIT TO F14E A SI�NED . � ZSTATEMENT THAT HE OR SHE IS UCEN6ED PURSUANT TO THE PROVISIONS OF THECONTRACTOFlS L4 � CENSE 4AW(GUPTEFI9(COIAMENCINO WI'fH SECTICN ta0o)�OK DIVISION 3 OF THE 6U31N�$S�ANp PRO- � � POOVS(12 FESSIONSCODE)OR7HA7HEORSHEISEXEMPTTHEREFROMAN�THEBASISFOflTHEALLEOEDEXEMR (!} l � TION.ANYYIOUI'IONOFSECTIDN7o37.58VM1YAPPLiCAN7FORAPERMITSUBJEC7STHEAPPLICANTiO Z (jg_Rpp} � A GIVIL PENALTY OF NOT MORE TMAN fNE HUNDRED OOUARS(S5o0),I: , � - � ❑I,ASOWNEROFTHEPROPERTKORMVEMPLOYEESWI7HWAGESASTHEIRSOLECAMPENSA'f10N. 0 COmrtleYCial ' WILL DO THE WORK.AND THE STHUCTURE IS NOT INTENO6D OR OFfGRE�FOR SALE(SEC.76d9;BUS4 �J NESS/WD PflOFESSIONS COOE:THE CONTRACTORS LICENSE UW DOES NOT APPLY N AN OWNER OF � PROPERTYWHOBUILDSOFIACPROVESTHEREON,ANDWNO�OESSUCHWOHNHIAASELFORNERSELFOR = [[ THqOUGHHISORHEqOWNEKIPLOYEES,PROVIDEDTHATSUCFI'IMPROVEMENTSARENOTINTENPEDOR m � �'�� � OfFEREDFORSALEIF.HOWEYE0.THE6UILDINGORIMPROVEMENTI550lDWIT1INONEVEAROFCOMPLE Z 'TION,THE OWNERBUIIAER MALL HAVE THE BURDEN OF'PROVING THAT HE QR SHE DID NOT BUII.D OR � MPHOYEFORTHEPUHPOSEOFSAL�• � •'..:` .'... '� W ❑I,ASONMEROFTHEPROPFRTY.AME%CLUSIVELYCANTRACTINGWITHLICENSEOCQNI'RAC�fORS , - WTQ CONSTNUdT 7HE PROJEC7(SEC.7or4,BUS�NESS AND PROFESSIONS CADE:THE CON'TqACTORS U- V11U8IiOn ADJ.AREA CENSELAWDDESNOTAPPLYTOANOWNEROFAPROGERTVWMOBUILDSORIMP%OVESTNEREbN,AND � WHOCONTRACTSFORSIICHPHQIECTSWITHACONTRACTOR(S)LICENSEDPURSUAMTOTHE(pNiPAC- Y mqsuc�sEuw.). . �,���<,,; QUANTITY DESCRIPTION FEE � q 1 M7 E%EMPTUPAER 56C. B.&P.C.FOfl THIS REASON U 3 CL � OA7E OKMER V o LICENSED CONTRACTORS DECLARATION � -' ' -� � � ,,. W I HEPEBV AFFIHM UNDER PENAL7Y OF PERJUHY TNAT I AM LICENSED UNDER PROVISIONS oF CHAPTEH � � I^ � 9�COMMENCklO WI7H SECTION 1000)OF DIViSION 3 DF THE BUSINES&AND PROFES$IONS CO�E,AND z � MY LICENSE IS IN NLL FORCE AND EFFECT. m � LICENSE CLASS �� LIC.NO. �� .`��^�—��.,����.'.,��y � V DATE "� CONTRACTOR �_�(N�r��"T-'11_t-�� d W j- (� � WORKERS'COMPENSATION DECLARATiON �Y �y�Ci ¢ � I HEREBY AFFIRM UNDER PENALTV OF PEiUURY ONE OF THE FOLIOWING DECLApATONS: � -' ' � ' "'' ' � Z Q � ^IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSL'REFORWORKERS' 2 � COMPENSA710N.ASPROVIDEDBYSECTION37000FTHELABORCO[?E,FORTHEPERWRMANCE 'U OFTNE WORK FOR WHICH THIS PFRMIT IS ISSUEO. � � W �1 HAVE MI�WILLMAIMAIN WURKERS'COMPENSATION INSURANCE.AS REQUIREO BV SECTION �� � � - Q 37ooOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS . ISSUEU.MYWORKERS'WM7ENSRTIONINSUflANCECAFFN�RANDPOLICYNUMBERARE: CONSTRUCTION � CARRIER_ ���X L_ PLNN R£VIEW Z POI�CYNUMBER _---�-.—.�d- �LECTFIC � ¢ Q �ni�s5�cna�r�mr�oreE�ooF7�aEr�ar�s�a7aaEHuroriEomtu+as(Sico�oa�Ess�. PLUMBING Zw I CERTIFlTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUE0,1 MECHANICAL . : ,: __'__ _ _ �;} SHALLNOTEMPLOYANYPERSONINANYMANNERSOA5708ECOMESUBJECTTOTHE ' � � WORKERS'CAMPENSATqN IAWS OF CALIFORNIA.AND AGREE THFT�F 1 SHOULD BECOME INSPEGTION FEE � SUBJECT TO THE WORKERS'COMPEtJSATION PROV�SIONS OF SECTION 37o00f THE LABOfl '- � � - - � - . CADE,I SHALL F TNW�TH COMPLY WITHTHOSE PPOVISI.ONa' ISSUANCE -�� �� o .S� f APPLICANT: � 'r(�� SMIP p DATE:_ — r — � � � w ENERGY P!C ��� � � J WARNINGFAIIURETOSECUREWORNERS'COMPENSATIONCOVERAOEISUNLAWFUL,AN�SHALLBE �y SUBJECTAN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUN�RED THOUSAND I ENERGY PERMIT DOLURS(5100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDBD FOR IN . . ... � SECTION 37080F lliE LA90R CODE,INTEREST,ANO ATTORNEV'S FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE-A�T FEE: � � � � � � + S 1 HEREBYAFFIRM UNUEfl PENALTY OF PERJUflV THAT 7HERE IS ACONSTflUCTION LENDING AGENCY ` ' � �' n- FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.). � � � - . . . � Z W , � LENpEP5 NAME ' - E A � LENDER'S ADDRESS . �+ . ,_� ,, ��o ` '�� � ICERTIFYTMATIHAVEfiEADTH�SAPPLi�AT10NANDSTATEhiATTH[ABOVEWFORMATIONISCORRECT. - TOTAL FCGS I W I AGREE i0 COMPLY W1TH ALl CM AND COUNTY ORDINANCES AND STATE LAWS R9ATING TO BUILDING" � � CONSTRUCTION,ANDNEREBYAUTHORREREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE ZABOVEMBdTIONED PflOPERTY FOR INSPECTWN PURPOSES. COMMENTS ' 13".>,�', = J d 1'��( \A -- _ �'' � ,�p m PERMITT NAMEIP� - �. °�.�,� ,'° � �[I � �.4 5-zt�c�� �, a,;y ,, ;� � S16NATUREDFPERMI EE DATE ' �I = RECPT.NO. PAID BY VALIL7Al10 � ~ �� � � WHITE-0epartmen4 Copy,YELLOW—finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy � - , , . ,. 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