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HomeMy WebLinkAbout12261 (14) _�,a - CITY OF DIAMOND BAR ` ` DEPARTMENT OF COMMUNITY&DEVELOPMENT SER ICES � � 21660 E.Copley Drive 5mte 140 ,., (909)860-3195 Fax(909)861-3117 � '��i/� PRESS �� BUYLDTNG P�RN,t�`�'`:�f��.'T�A'rION . ; y�° FIRMLY ,_ � ... --.m . .. > .. .,;:, � JOBSITE p �s � �j'� o ADDRESS -Z'���-''�t �+�-e21�.�V��A���^� DATE CATION � ��`'� NUMBE �"'��_" #/C r � issuE TYPE occ APN lOT TRACT DATE CONST. GROUP p OWNER '�'z�d2�"T��s'�i��v�Z. C�N�.--�?K�� "" ADD ESS �� � ' ' I ZONING SETBACKS W -Z�"� FRONT RW ❑ z CITY i?�r'�-+G�'�ti��i'�7`�. ZIP "'�c " T 1��� ��.-. REAR ❑ g APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR �c z; � SIDE n ADDRESS "�r� S e '� :tE. � CITY I.^�lrs�tt�f�r`t7. C.� ZIP� TEl`� "d� `��..� PROPOSED USE o ARCH/ENG/ z OESIGNER w NO.[SWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � cn bESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDERDECLARATION ,_ �.. ,.' ., „ . SFR/ADD/REM O p I HEREBY AFFlqM UNDER PENALTY OF PERJURY THAT i AM EXEMPT FROM THE CONTRACTORS LI� Gafaoe/COfpOlt LLI CENSEUWfORTHEFOLI.OWINGREA50N(SEC.7031.5BUSINESSAN�PROFESSIONSC�DE�hN`/CITVOR (f� � C.1 COUNTYWHICHRC-0UIRESAPERMITTOCOkSTRUCT.ALTER,IMPROVE,DEA�OLISH,ORREPA�PANVSTRUC� W Pg2i0lD9Ck '� TUR�PRIOR TO ITS ISSUANCE,ILLSO REdIJIRES TNE APPL�CANT FOR BUCH PEiM11T70 FICE A�SIGNEO W : STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF TNE CONTRACTORS�L4 - � CEN9ElAW(CHMTERB(COMMENCiNO'MTHSECfION700o�OFpIVI510N30FTHE9U$�NE$SANp'PRO- �'�' Po0VSp8 FESSpNSCODEJORTFIATHEOH5HE15EXEMPTTHEREFPOMqNOTHEBASISFOR7HEALLEGEDEREMP� (� � TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEApPCICANTTO � pe:p�t � ACIVIIPENALTYOFNOTMORETHANfNEHUNDRE000L1ARS(5500).): ' '"-'� '����'�. . � ❑I.ASONMEROFTHEPROVERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOIUPEN5ATIDN, L� CororoerCldi - WILL DO THE WOqK,M10 THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE�(SE�,70d4',�B1151- J � NESSANU PROFESSIDNS CODE:THE CONTRACTOPS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � , ���� . PROPERTYWFIOBUII.DSORIMPROVESTHEREON,ANDWHODOESSUCHWORHFVIMSECFORfIEH�SELFOR • -Yl'�~ CL Ti1HOUGHHI50RHEROWNEMPLOYEES,PAOVIDE�THATSUCWIMPROYEMENTSARE�NdTINTENDEQ�pR m � -' � 0 OFFEREDFORSALEIf,FiOWEVER,IHEBUILDWGORIMPFOVEMENTISSOLAWITHINONEVEAROFI�'AMPLE � TION,THE OWNER�BUILDER WILL HAVE 7HE BURDEN OF PROYING THAT HE OR SHE O�ID NtlT BUILD Ofl = IMPROVE FOR THE PURPOSE OF SALE). �,^_�I�i:i,.'..!! :I I�'' �` ❑1,AS ONMER OF THE PROPERTY,AM EXCWSIVELY CANTRACTING WITH LICENSED(XJNTf1ACTORS � TO CONSTRUCT THE PR0.IECT(SEC:)DIa,BUSINESS AND FROFESSIONS CODE:TNE SONt'HqCfORS LI- V81U2ti00 ADJ.AaEA - W CENSEUWDOESNOTAPPLYTOANOWNEflOFAPROPERTYWHOBUILDSORIMFROVESTf�i�RE�ON,AND � tMT1000NTRACTSFORSUqiPROJECT3WITNACONTRACTOR(SjLiCEN3EDPURSUANTTOTHECONTRAG CQUANTlTY DESCRIPTION FEE Y TORS LICENSE U1W.). ' � ❑i AM IXEMPT UNDER SEQ __8.&?,G FOR THIS REASON q � - � U � � DATE OYlNER U o W � LICENSED COPITRACTORS DECWRATION W � I HEREBYAFPIRlA UNDER PENALTY OF PERJUHY THAi IAM LICENSE�UNBER PROVISIONS OF CHAPTER � d B(COMMENCINfi WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND Z X W LICENSE IS IN FULL FORCE ANO EFFECL � o LICENSE CLASS �� LIC.NO. ����1'��� � h �, ���p�,r C � �'��'p'���� i V DATE � '� -`� CONTRACTOR f��}�� p-`�„ 4• ._�L;n 67.t � WORKERS'COMPENSATlON DECLARATIQN --a,� � IHEREBYAFPIRMUNDEFPENALTYOFPERJURYONEOFTHEFOLLAWINGDECLARATIONS: z ' � _IHAVEANDWILLMAINTAfNACERTIFICATEOFCONSENTYOSELF-INSUREFOftWORKERS' a 2 CAMPENSATION.AS PROVIDE�BV SECTION 3700 oFTHE LABOR CODE,FOR THE PERFORMANCE C.) Q OFTHF WORK FOq WHICHTHIS PERMIT IS I33UED. g � t HAVEAND WILL MAIMA�N WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION Q 37aDOFTHELPBORCODE,FORTHEPERFORMANCEOFTNEWORKFORW111CHTHISPER�AITIS ISSUED.MYbVORKEFS'COMPENSATION INSURANCE CARRIER AN�PO�LICV fdUMBERARE: CONSTRUCTION � CARRIER �-��k �-y —�7 ��1 �C:�� PLAN REVIEW � POL�CYNUMBEP Ci-�d '' 6 L.-. � ELECTRIC � (THISSECfIONNE�t�pT8E00NiPLETmOF71iEPElB.lffISFOFONENUNDPEDLCd.L�iiS(5100JORLESS). PLUMBING ( Z ICEftTIFYh1ATINTHEPERFORMANGEOFTHEWORKFORWHICHTHISPERPdITi5155UE�,1 MECHANICAL t} SHALINOTEMPLOYANYPEflSONINANYMANNER500.STOBECOMESUBJECTTOTHE +� � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIfISHOULDeECOME INSPEC7iONFEE = SU&IECT TO THE WORKERS'COMP ROMIu ONS OF SECTIDN J]o00F THE LABOR CODE,15� SHALLFORTHwinicoM vunn+rHosErao�i�rw�' ' ISSUANCE l o '�l�'�� � DATE: APPL�CAN�"'� ` SMIP � � WARNING:FAILUPE TO SECURE WORKERS'COMPENSATION COVERAGE IS IJNIAWFUL,ANO SHALL BE ENERGY P/C . py SUBJECTANEMPIOYERTOCqIMINAIPENALTIESANDCIVILFINE6UPTOONEHUNDREDTHOUSANO ENERGYPERMIT � DOIIARS(5100,000),INADDITION70THECOSTOFCOiAPEN5AT10N,DAMAGE5A5PROVIDEDFORIN � £ECTbN370BOFTHELABOftGqOE,INTEP,EST,ANDATTORNEYSFEES. RETENTIONFEE: _ � CONSTRUCTION LENDING AGENCV PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALTYOFPERJUPYTHATiH[REISACONSTRUC710NLENDINGAG[NCY � FOR THE PERFORMANCE OFTHE WORK FOR WHICFI THIS PERMIT IS ISSUED(3EC.3087,CIV.C.). Z W � IENDER'S NAME � "� -' ' ' ' t— LENDER'SADDRESS W ICERTIFYTHATIHAVEREADTHISMPLICAiIONANOSTATETIiATTHEA80VEINFOR�AATIONISCARRECT. TOTAL FEC�7 � q(• � I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDWANCES AND STATE LAWS RELATINO Tp 9UILDING � CONSTRUCTION,AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUN7V TO ENTER UPON THE ABOVE-MENTIONEO PPOPEflN FOR INSPECTION PURPOSES. COMMENTS � �,s�, "���.�-�+��..�/ --- m PERMITTEE 1 E(PRINT) � - � �---� � .�� � S�ONATUREOFPERMI DATE , - = RECPT.NO. 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