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HomeMy WebLinkAbout17156 (23) � �` _ CITY OF DIAMOND BAR � ,/'� DEPARI'MENT OF COMMUNITY&DEVELOPMENT SERVICES,� r�` a �� 21825 E.Copley Drive � (909)860-3195 Fax(909)861-3117 � PRESS -�v���� BUILDINGPERMITAPPLICATION FIRMLY o� JOBSITE � . APPL�CATION G{ "� � PERMIT ���t / p/C'rl� ADDRESS DATE � NUMBER�_�...��� #�„L � ISSUE TYPE OCC APN LOT TRAC DATE CONST. GROUP p OWNER � y o ADDR S ( IO ZONING SETBACKS z CITY ZIP TE � FRONT Ryy � � APPLICANT TEL. REAR ❑ z SIDE/SIDE STREET qNr ❑ 4 CONTRACTQ R Y'I SIDE p ADDR S l 1^I'1 � � CITY ZIP j !O TE t� PROPOSED USE � ARCH/ENG/ z DESIGNER � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFlfiM UNDER PENALTY OF PEFJURY TMAT i AM EXEMPT FROM THE CONTRACTORS LI� GdfdJ2/C8�P011 W CENSELAWFORTHEFOLLOWINGREA50N�5EC.7031.5BU5iNESSANOPROFESSIONSCODE:ANVCITYOR (� U COUNTVWHICHREQUIRESAPERMITTOCONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG � �O W TUFE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES'HE A�PLICAN7 FOR SUCH PERMITTO FlLE A SIGNED W PafiD/DBCk � STATEMENT THAT HE OR SHE IS LICENSED PlJRSUAN'TO 7HE PROVISIONS OF 7HE CONTRACTORS LI� � CENSE LAW(CHAPTER 9�COMMENCING WRH SECTION 1000)OF DIVISION 3 OF THE BUSINESS AND Pq0- � Pool/Spa O FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALIEGE�EXEMP- (� V TION.ANYVIOLATIONOFSECTION7o31.5BVANVAPPJCANTFOqAP[RMITSUBJECTSTHEAPPLICANTTO Z Re-Roof F ACIYIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(SSoO).): Z ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfnrtlBfCifll WILL DO THE WORK,NNO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC.7046,6U51- J � NE55 AND PROFESSIONS CO�E:THE CONTRACTORS UCENSE lAW DOES NOT APPLV TO AN OWNER OF = PROPEH7V WHO BIJILDS OR IMPROVES THER'eON,AND WHO DOES St1CH WORN HIMSELF OR HERSELF OR � THROUGHHISORHEROWNEMPLOVEES,PROVIDEOTHATSUCHIMPFOVEMENTSARENOTINTENDEDOR m � OFFEREDFORSALEIF,HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDIMTHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE�ID NOT BUILD OR � IMPROVEFORTHEPUR70SEOFSALE�. w ❑I.ASONMEROFTHEPROPERTV,AMEXCLUSNELYCONTRACTINGWITHLICENSE�CONTRACTORS [[ TO CONSTRUCT THE PPQIECT(SEC.7oai,BUSINESS AND PROFESSIONS COOE:THE CONTRACTOPS LI- „ �2IU8I1011 ADJ.ARE W CENSEIAWDOE3NOTAPPLVTOANOWNEROFAPROPEFiTYWHOBUILD50RIMPftOVESTHEREON,AND � "� � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTOTHECONTFAC- l QUANTITY ESCRIPTION FEE Y TORS LICENSE LAW.). � ❑I AM EXEMFT�NDER SEC. __ B.&P.C.FOR THIS REASON Q � U , tL � OATE OWNER H Z ' _ '.�.' __"__. .. . _'....,_...__ . __..-...._....� "_. . ___. 0 W LICENSED CONTRACTORS DECLARATION � ¢ W � I HEREBYAFFIRM UNDER PENAL7V OF PERJURY TNAT IAM'_ICENSED UNDER PROVISIONS OF CHAPTER � d 9(COMMENCINGWITIISECTION70o0�OFDIV15!ON30FTHEBUSINESSANOPROFESSI�NSCO�E,AND Z X MY LICENSE IS IN FULL FOflCE AND EFFECT. /�1 � LICENSECLASS �+ � 1 LIC.NO. SI e f O� � U OATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION ¢ � 1 HEREBYAFFIRM UNDER PENALNOF PERJURV ONEOFTHE FOLLOWING DECLARAT10N5: Z z _I HAVE AND WILL IAAINTAIN A CER7IFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _ ¢ CAMPENSATION.ASPfiOVIDEDBYSECTIDN37ooOFTHELABORCOOE,FORTHEPERFORMANCE U - Q OFTHE WORK FOR WHICH TNIS PERMIT IS'SSUED. � QQ � I HAVE AN�WILL MAINTAIN WORKEflS'COMPENSATION INSURANCE,AS REOUIRE�BY SECTION ///��� �' � ` � 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF TFE WORK FOR W41CH THIS PERMIT IS r / Q� ISSUED.MV WOFKERS'CAMPENSATION I URANCE CARW�R ANO POIICV NUMBER AflE: CONS CTION (�� Q ,,y � CARRIER �� u _ PLAN REVIEW + • ZPOUCYNUMBER �„� �' �IrO�Z.C� ¢ —�---�— ELECTRIC 0 (iHt55ECTI0NNE�NOTBECOMPI.ETEDOFTHEPERMffISWRONEHUI�ARE�WLLARS(5100)ORLESS). PLUMBING Z' ICERTIFYTHATINTHE?ERFORMANCEOFTHEWORKFORWHICHTHISPERMIT�SISSUED,I MECNANICAL � SHALLNOTEMPLOVANYPERSONINANVMANNEFiSOASTOBECONESUBJECT70THE �-�'-�"^=�� ��� •"-r^ • q� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFE. p�xe• � � SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37oa Of THE LABOF �"'��` �-� � -""- , � COUE.ISHALLFOftTHWiTHCOMPLVWITHTHOSEPROVI5ION5. ISSUANCE 0 / p OA7E � �0 I APPLICANT� SMIP � � r ._71 1 1 I 1 i ,� J WARNING FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFVL,AND SHALL BE ENERGY P/C Q � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDqVILFINESUPTOONEHUNDREDTHOUSAND ENERGVPERMIT _ �� OOLLARS(E10o,o00;�.W ADDITION TO THE COST OF COMPENSATIOM1,DAMAGES AS PROVI�ED FOR IN --'E. , , � SECTION 3708 OF THE LABOR CODE,INTEREST,ANO ATTORNEV'S FEES. RETENTI ON FE�^�`�"-"-' ":- ' '"'-'`"" OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBVAFFIflM UNDER PENALTYOF PERJURV THATTHERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORN FOR WHIGH THIS PERMIT IS ISSUED(SEC.3091,CIV.G.). Z w � LENDER'S NAME F- LENDER'SADDRESS � TOTAL FEES , f (� � ICEflTIFYTHATIHAVGREADTHISAPPUCATIONANDSTATETHATTHEABOYEMFORMATIONISCORRECT. �T W IAQREETOCOMPLVWITHALLCITYANDCOUNTVOADINANCESANDSTATELAWSRELATiNGTO8UIL0ING � � CONSTRVGTIDN,ANOFEREBYAUTHOFREFEPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE Z ABOVE-MENTIONED PROPERTY FOR INSPECTION PUFPOSES. 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