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HomeMy WebLinkAbout10503 (5) EXF IRED � CTfY OF DIAMOND BAR ���"'"" • � �� � n COMMUNTTY DEVELOpMEI�T DEPARTMENT O C� � 3 �=��0 21660 E.Copley Drive Suite 190 (909)860-3195 Fax{909)661-3ll7 PRESS �'""', BUILDING PERMIT APPLICATION FIRMLY _ .: oy JOBSITE � °�� � APPLICATION ��/� PERMIT � /p ADDRESS � DATE � NUMBER # � ISSUE TYPE OCC APN L T TR T DATE CONST. GR�UP p OWNER p ADDRES P' ZONING SETBACKS z CITY ZIP TEL. � J' FRONT qy�/ ❑ o APPLICANT TEL. S DE/SIDE STREET RW ❑ � CONTRACTOR u . � . SIDE ❑ ADORESS � CITY IP � � ` TEL. "� PROPOSED USE o ARCWENG/ �z DESIGNER NO.DWEL. NO. NO. n. ADDRESS � CITY 21P TEL UNITS STORIES BEOROOMS � cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION pC OWNER-BI;ILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRI.1 UNDER PENALTY oF PERJURY THAi I AM E%EAIPT FROM THE CON7pACTORS LI- G8�8JB/CfllPOfl W CENSELAWFORTHEFOLL0IMNGREASON(SECJo37,56USINESSANOPROFESSIDNSCODE:ANYCITYOR (n U CWNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOUSH,ORREPAIRANYSTRUC- W patiolDeck W TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W .d,P- STATEMENT TNAT HE OR SHE IS UCENSED PURSUANT TO 7HE PROVISIONS OF THE CANTRACTORS Lb LL � CENSE LAW(CHAPTEP 9(COMMENCMG WI7H SEC710N 700D)OF DIVISION J OP THE BUSINESSANO PqD- POOUSp3 FESSIONSCODE)Ofl7HATHEORSHEISEJ(EMPTTHEREFROMANOTHEBASISFORYHEALLEGEDExEMP- (� V TION.ANYVIOLATIONOFSECTION7031.SBVANVAPPLICANTFOR0.PERMRSUBJECTSTHEApPUCANTTO Z Re-floof A CIVIL PENALTV OF NOT MORE THAN FNE HUNDREO bOLLARS(f500).j: ' - - � OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTFIEIRSOLECOMPENSATION, � Commercial z WILL 00 7HE WORK,AND THE STRUCTURE IS NOT IN7ENDED OR OFFEqEO FOR SALE(SEC,7oaa,BU51- J � NE55 ANO PROFESSIONS CODE:THE COPoTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PFOPERiY WHO BUIL�S OR IMPROVES TMEREON,AND WHO OOES 5UCH WORK HIMSELF OR HERSEIF Of1 Q THROUGH HISOR HER OWN EMPLOYEES.PROVIDED THAT�SUCH IMPROVEMENTSARE NOT WTEN�EOOR m � OFFEREDFOFSALE.IFFIOWEVER7I�EBUILOINGOFiIMPROVEMENiISSOI�WITHINONEVEAROKCOAIPLE- Z TION,7ViE OWNER-BUILOER WILL HAVE THE BURDEN OF PROVING TNAT HE OR SHE OID NOT BUILD OR = IMPROVE FORTHE PURPOSE OF SALE). w ❑1,ASOWNEROFTHEPROPERTV,AMEXCIUSWELYCONTRACTWG,WITMLICENSEDCON7pACTORS � TO CONSTRUCT TNE PflOJEGT�SEC.'/o44,BUSINESS AN�PROFE5510N5 CODE:THE CONTRACTOflS LI� VdlUa�lOfl ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNeROFAPROPERTYWHOBUILDSORIMPROVESTHEPEON,AND � WHOCON7RACTSFORSUCHPROJECTSWITNACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAC� QUANTIN OESCRIPTION � FEE Y TORSLICENSELAW.�. 0 ❑1 AM E%EMDT 11N0ER SEC. B.&P.C.FOR THIS REASON Q �y U � DATE OWNER I-� Z C� � LICENSED CONTRACTORS DECIARATION W ¢ � I HEPEBV AFFIRM UNDER PENALTV OF PERJURV TNAT 1 AM LICENSED UNOER PROVISbN&OF CHAPTER � d 9(COMMENqNO WITN SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESS�ONS CADE,AN0 Z QMY LICENSE IS IN FULL�oRC'EAND EFFECT. ��� M � � UCENSE CLASS C �t`� LIC.NO. V DA7E_�C? CONTRACTOR�=`�+�7'�� ., 0.�. ,�. W / J°� � � � WORKERS'COMPENSATION DECLARATION ` �l-kr�"d z �� I NEPEBY AFFIRM UNDER PENALTV OF PERJURY ONE Of THE FOLIOWING DEdARAT�IONS: +� � V Q Z _IHAVEMI�WILLMAINTAINACERTIFICpTEOFCANSENTTOSELF-INSUREFOHYVORKERS' _ � Q COMPENSATION,AS PROVIOED BYSECTION 3700 OF THE LABOR CODE,FOfl THE PERF-0RMANCE C� OP THE WORK FOR WHICH THIS PERMIT IS ISSUED. � �(J QW ,/�,IHAYEANOWILLMAINTAINWORKERS'COMPENSA710NINSURANCE,ASREWIREOBYSECTION 37ooOFTHEIABORCOOE,FOR7HEPERFORMlWCEOFTHEWOPoCWRWHICHTNISPERMITIS ISSUEO.AfY WOFKERS'COMPENSATKNJ INSURANCE CARRIEFAND POLICV NUMBEpARE: CONSTRUCTION Q �-.1 ] CARflIEF J'T �� 3 i � pLqN REVIEW z POLICYNUMBER ELECTRIC ¢ ��. (iHIS5ECT10NNE�NOTBEOJNPLEfmOFIFiEPERMffISFORONEHUt�DPEDD011ARu(S10%ORLESS�. PLUMBI �W �1'R Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI7 IS ISSUED,1 � ,,.MECHANICAL � C3 SHAt1 NOT EMPLOV ANV VERSON�N ANY MANNER SO AS TO BECOME SUBJECT TO THE Uj WORKERS'COMPENSATION LAWS OF CAUFORNIA,AND AGREE THAT IF I SHOULD BECOME � INS ECTION FEE /� SU&1ECTT0 TY.E WOflKERS'COMPENSATION PRpVISIONS OF SECTIJN 3700 OF THE LABOR � � COOE,I SHALL FORTHWITH COMPLY WITH THQSE PROVISIONS. ISSUANCE C� � � � �'ia. F p DATE: qPPLICANT: SMIP W � WARNINGfA1LURETOSECUREWORKERS'COMPENSATIDNCOVERAGEISUNLAWfUL,ANDSHALLBE ENEFiGYP/C J SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNbRE�THOUSAND � y¢ .��„ DOLURS(5100,Oao).NAD�ITIONTOTHECOSTOFCOIAPENSATION.DAMAGESASPROVIDEOFORIN ENEFGYPERMIT _�%� �����/ J SECTION 3�08 OFTHE LA60R CODE,INTEREST,AND ATTORNEI"S FEES. � '4i" � RETENTION FEE: OCONSTRUCTION LENOING AGENCY pqE-ALT FEE: � I HEREBV AFFlRM UNDER VENALTV OF PERJURY THAT THENE IS ACONSTRUCTION LENOING 0.GENCV � FOR THE PERFORAAANCE OFTHE WOPK FOR WHICH THIS PERMIT IS�SSUED(SEC.3007,CIV.C.). Z W � LENDER'S NAIAE � ; , . F— LENDER'SADDRESS � ¢ ICEFTIFYTHATIHAVEREADTHISAPPI�CA?IONMJDSTATETHATTHEABOVEINFOflMATIONISCORRECT. TOTAL FEES � w I AGREE TO CAMP�Y WITH ALl CITYAND COUNTY OROINANCES AND STATE IAWS RELATING TO BUILDING� ° d � CqNSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVE50FTHI5CAUNTYTOENTERUPON7HE . � . ..:1'�.: Z A80YE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. .� _ ^ �� � ���� COMMENTS , ���c s m PERMI7TEE.NMIE(PFIN7� �c Q -. i � �� � � �* �f��s� � . 9d6'�j,,:�. (/� StlrpffT�P HMITT� DATE = RECPT.N . PAID 8Y VAUDATION � WHITE—Deparlment Copy,YELLOW—Finance Copy.PWK—Assessor Copy,GOLDENROD—File Copy,GREEN—AppllcanYs Copy - ` - i ����Ys�:::� . i� ;. ,... , � ,. . , . , , . : ;� . . ' � J� �.* � � � �' M�+� . .. ;�` � "F � � �. � ���; � �t ��w"+��� �� �`�� �� �Af$ . ,�, y�ryp@q,q� p�q�y� �{�� qq �q ., .. . . l"n.. _ �'.., . ^�B�O�R �����F'�md'� H 3Cv.'+al�W l��. . . . . . .�� . .���. y�„m"" � ,;:YvJy:Y�� , _ . . . .. . 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